Health inspection·May 27, 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 Based on observation, interview and record review the facility failed to ensure safety measures were implemented for three residents (R1, R2, R3) who fell during cares and/or transfers of three residents reviewed for falls. This failure resulted in R1 sustaining a fractured left humerus. The findings include: Facillity Policy/Safety and Supervision, last revision date 02/2025, documents: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: Bed/Chair Safety; Safe Lifting and Movement of Residents. Facility Policy/Managing Falls and Fall Risk dated 2001 documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Fall Risk Factors Environmental factors that contribute to the risk of falls include: Wet floors Obstacles in footpath Footwear that is unsafe or absent. Resident Factors that may contribute to the risk of falls include: Lower extremity weakness Page 1 of 4 145556 145556 05/27/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0689 Poor grip strength Level of Harm - Actual harm Medication side effects Residents Affected - Few Functional impairments Medical factors that contribute to the risk of falls include: Neurological disorders and Balance and gait disorders. Facility Policy/Safe Lifting and Movement (undated) documents: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Facility Policy/Bath, Tub/Shower dated 2001 documents: Place a non-skid bath mat on the floor where the resident will step in/out of the tub or shower. Assist the resident out of the tub or shower. Hold firmly to the resident. Move slowly. 1. Current Physician Order Summary Report indicates R1 has diagnoses that include Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant Side, History of Falls, Generalized Muscle Weakness, Heart Disease, COPD (Chronic Obstructive Pulmonary Disease), and Fatigue. Final Fall Investigation Report: dated 5/18/2025 indicates: On 5/17/2025 R1 was being assisted off of the toilet by V4, CNA (Certified Nurse Assistant) and R1 lost balance while stand-pivoting from toilet to wheelchair. Report indicates V4 was able to help minimize R1's fall and R1's left arm landed on the foot pedal of his wheelchair with left arm behind his back. After falling, R1 complained of left shoulder pain. R1 was sent to ED (Emergency Department) for evaluation and treatment. R1 returned to the facility at 4:30am on 5/18/2025 with diagnosis of left proximal end humerus fracture. Order for shoulder immobilizer and prescription for Norco (opioid) for pain. On 5/27/25 at 10:50 AM R1 was in his room, wearing an oxygen cannula sitting in a wheelchair with one left footrest attached to the wheelchair. At that time, R1 stated he was being transferred off the toilet and was holding onto the grab bar nearest the toilet during the transfer (on 5/17/25). R1 stated he was wearing shoes (pointing to the shoes he was wearing). R1 stated the CNA did not use a gait belt, But they do now. R1 was wearing an immobilizer on his left arm and stated he was still having pain and receiving pain medication. 145556 Page 2 of 4 145556 05/27/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0689 Level of Harm - Actual harm Residents Affected - Few On 5/27/25 at 1:52 PM V4, CNA, stated she was assisting R1 off of the toilet (on 5/17/25). V4 stated R1 stood up, holding onto the grab bar with his right hand. V4 stated as R1 was attempting to step/slide/turn around to sit in the wheelchair, R1 lost his balance, fell to the side with his left (flaccid) arm behind his back and fell onto the left footrest of his wheelchair. V4 stated R1's pants were almost up and so she had nothing to grab onto to try to prevent R1 from falling. V4 stated sometimes they will assist/guide R1 during a transfer by grabbing onto the waistband of R1's pants. V4 stated she did not use a gait belt during the transfer with R1 because she was never trained to use one with him, but they now are using a gait belt for all transfers with R1. On 5/27/25 at 10:50 AM V3, Restorative Nurse, stated the CNAs were not required to use a gait belt with R1, however she was aware they were sometimes holding onto R1's pants during transfers. V3 stated that due to R1's medical diagnoses some days he is stronger than other days. V3 stated a gait belt is now required during all transfers. 2. Current Physician Order Summary Report indicates R2 has diagnoses that include Muscular Dystrophy, Lack of Coordination, Dependence on Wheelchair. Progress Note dated 4/21/25 at 10:03 PM indicates V8, CNA, was pushing R2 in a shower chair out of the shower when R2 slid out of the shower chair onto the floor. Note indicates V8 stated, (I) thought (I) put the seatbelt on but don't think it clicked. Note indicates R2 did not receive any injuries from the fall. Fall Details Note dated 4/21/25 at 10:43 PM indicates R2's fall was witnessed, occurred in the bathroom and the reason for the fall was (R2) did not have seatbelt secure and (R2) slid out of the chair. Current Care Plan indicates R2 is high risk for falls related to deconditioning, gait/balance problems, lack of awareness of safety needs. Care Plan indicates R2 has poor trunk control with poor sitting balance. On 5/27/25 at 11:10 AM V3, Restorative Nurse, stated after R2 fell from the shower chair, maintenance checked all shower chairs and safety belts on the chairs and all were working and locking properly. At that time, V3 demonstrated the lock mechanism on the shower chair R2 slid out from (on 4/21/25). The lock portion of the shower chair safety belt produces a loud clicking sound when lock is fully engaged. The lock could not be pulled apart or loosened when locked properly. 3. Current Physician Order Summary Report indicates R3 has diagnoses that include Diffuse Traumatic Brain Injury Attention Deficit Hyperactivity Disorder, Abnormalities of Gait and Mobility, Unspecified Dementia with Behavioral Disturbance, Cervical Spinal Stenosis. Post Fall Evaluation Note dated 3/21/25 at 1:18 PM indicates R3 fell on 3/21/25 at 11:45 AM. Note indicates R3 was in the shower area and staff were attempting to pull up R3's pants when R3 lost balance and fell. Note indicates reason for fall was unsteady gait and loss of balance. Note indicates R3 sustained a mid-back superficial abrasion. Current Care Plan indicates R3 had a change of plane with minor injury after falling onto his buttocks in the shower area due to floor being wet. On 5/27/25 at 2:00 PM V9, CNA, stated she was the CNA assisting R3 in the shower on 3/21/25. V9 145556 Page 3 of 4 145556 05/27/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0689 Level of Harm - Actual harm stated R3 was done with his shower and stood up as she was trying to dry his bottom when R3 slipped and fell down. V9 stated there was no anti-skid mat or strips on the shower floor at that time. V9 stated sometimes she put a towel down for a resident to stand on but she did not put one down before R3 stood up. Residents Affected - Few On 5/27/25 at 1:05 PM V3, Restorative Nurse, stated the floor in the shower was wet when R3 fell. V3 stated R3 was not wearing socks or shoes when he fell. 145556 Page 4 of 4