Health inspection·May 9, 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 provide safe bed mobility assistance for one (R1) of three resident reviewed for resident injury and siderail use in a sample of seven. These failures resulted R1 incurring a right femur fracture, a nasal fracture and a laceration requiring sutures. This was identified as past non-compliance that occurred from 04/02/2024 to 04/05/2024. Findings include: The 5/7/2024 admission Record shows R1 with diagnoses to include morbid obesity, Hemiplegia and Hemipariesis following brain bleed affecting the left non-dominant side, and contractures. On 5/7/2024 at 10:20 AM R1 laid in bed with an air mattress and one quarter siderail at the top of each side of the bed. R1 had an immobilizer brace to her right lower leg, and contractures to her feet and hands. R1 stated her leg and nose were broke when she was being provided personal care with one staff person instead of the two staff she requires. R1 stated she uses the siderail to assist staff with positioning which was not loose but when she was rolled onto her left side all her weight was placed onto the rail and it broke off causing her to fall to the floor. R1 stated she has had little use of her extremities on her left side, and limited ability to move her right leg, right hand and right arm. On 5/8/2024 at 1:22 PM V4 (Nursing Assistant) stated she was alone providing care to R1 and when V4 turned R1 onto her left side, with R1 assisting and grabbing the siderail with her right hand and arm, the siderail broke and R1 fell to the floor. V4 confirmed R1 was a 2 person assist but was not aware at the time of this incident. The Facility Event Report dated 4/2/2024 at 4:15 AM documents R1 was turned on her side while being changed, the siderail broke and she fell from the bed onto the floor landing on her face. R1 incurred a laceration to the bridge of her nose and complaining of pain and was transferred to the hospital for evaluation. R1 returned from the hospital with diagnoses to include a nasal fracture and laceration with 4 sutures and a right lower leg immobilizer for a right femur fracture. On 5/7/2024 at 12:18 PM V2 (Director of Nurses) stated R1's care card used by the direct care staff to determine resident care needs showed R1 as one person assist for bed mobility. V2 stated as she investigated this incident, she discovered R1's care card should show R1 as a two person assist for bed mobility per her assessments and plan of care. V2 stated R1 denied the siderail being loose during the incident and the facility was unable to prove the siderail failed or was not secured properly Page 1 of 3 145538 145538 05/09/2024 Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401

F 0689 during this incident. Level of Harm - Actual harm On 5/7/2024 at 12:55 PM V5 (Nursing Assistant) stated she is familiar with R1, and R1 is a two person staff assist to roll from side to side in bed. V5 stated R1 can assist using the siderails but R1 is not steady when she is laying on her side and one staff is needed on each side so she does not tip over and fall out of the bed. Residents Affected - Few On 5/7/2024 at 1:10 PM V6 (Nursing Assistant) stated R1 always requires two staff to provide bed mobility because she is a larger person and needs assistance to turn. V6 stated when rolling R1 from side to side one staff person is placed on each side of the bed to keep her from toppling over and falling out of the bed. The Care Plan dated 3/17/2009 documents R1 with decreased mobility and transfers related to left sided Hemipariesis and obesity requiring the extensive assistance of two staff members for bed mobility. R1's Minimum Data Set, dated [DATE] documents R1 as cognitively intact and dependent on staff to roll right and left. R1's Weight on 03/11/2024 is documented at 203.0 pounds. The hospital After Visit Summary dated 4/2/2024 documents a Cat Scan of the facial bones showing a nasal fracture, a nasal laceration was repaired with sutures, and an X-Ray of the right knee showed a fracture of the distal right femur. On 5/8/2024 at 4:20 PM V9 (Nurse Practitioner) stated confirmed staff should follow the residents plan of care to ensure the safe provision of care. V9 stated, I agree if staff had followed her care plan and utilized the correct number of staff while performing her care during this incident she likely would not have fallen. V9 confirmed R1 incurred a fracture to her nose, laceration to her nose requiring sutures, and a fracture to her right lower leg during this incident. The manufacturers safety ring (siderail) instructions show the device can be used for residents weighing up to 1000 pounds. These instructions also document, . although the device is rated for such use, it may break if excessive force is exerted on the device. The surveyor confirmed through observation, interview and record review the facility took the following actions prior to the survey date, which were initiated on 04/02/2024 and completed on 04/05/2024, to correct the deficient practice: 1. R1's care plan and resident care card were reviewed and updated on 4/2/2024. 2. All residents with siderails had siderails inspected by Maintenance on 4/2/2024. Audits were conducted weekly by Maintenance for 4 weeks, then are ongoing monthly thereafter. 3. Audits for the use for the correct number of staff during the provision of care were completed by V2 (Director of Nursing) on 4/5/2024. Audits were conducted weekly by V2 for 4 weeks, then ongoing weekly thereafter. 4. Audits of the resident care cards and ADL (Activities of Daily Living) Care Plans were completed 145538 Page 2 of 3 145538 05/09/2024 Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401

F 0689 by Restorative Nursing on 4/5/2024. Audits were then conducted weekly for 4 weeks and will are ongoing weekly by Restorative Nursing thereafter. Level of Harm - Actual harm 5. Ongoing daily monitoring will occur for resident changes in condition requiring an updated plan of care. Residents Affected - Few 6. Staff reeducation occurred and was completed by 4/5/2024 as follows: A. Nursing and Nursing Assistants were inserviced on resident care cards, following provision of resident care per their care plan, and notification of any status changes. B. Housekeeping movement of resident care cards during room changes. 7. A Quality Assurance and Performance Improvement meeting was held on 04/03/2024. In attendance - V1 (Administrator), V2 (Director of Nurses), V3 (Assistant Director of Nurses) and V17 (Medical Director). These meetings were held weekly for 4 weeks, then resumed their regular monthly schedule. 145538 Page 3 of 3