Health inspection·February 9, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to provide supervision during toileting for a resident with a diagnosis of Dementia and failed to ensure fall prevention alarms were functioning for two of two residents (R25, R84) reviewed for falls in the sample of 31. Findings include: The facility's Fall Prevention Program, dated 10/24/22, states Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 6. High risk protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. 8. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 1. R84's Fall Risk Assessment, dated 1/11/23, documents R84 is at moderate risk for falls. R84's Pre-admission History and Physical, dated 11/27/22, documents R84 had a couple falls at home. R84's Minimum Data Set assessment, dated 1/17/23, documents R84 requires extensive assistance with transfers, ambulation, and toileting. R84's Care Plan, dated 1/2/23, documents the following: R84 had a fall at home, prior to facility admission, that resulted in a sacral fracture; R84's post fall intervention, dated 1/06/2023, to implement a pressure pad alerting device in bed and chair at all times to notify staff if R84 is attempting to self-transfer/ambulate as she does not always remember to ask for assistance. R84's Event Report, dated 1/6/23, documents R84 fell in her room while trying to move a bedside table and lost her balance. The Event Report ,dated 1/6/23, documents the Root Cause Analysis for R84's fall was (R84) attempting to self-transfer without assistance. R84's Hospital Record, dated 1/6/23, documents R84 fell at the facility and sustained a Lumbar Compression Fracture with Sacral Pain and a Scalp contusion. R84's Event Report, dated 2/8/23 at 2:37 AM, documents R84 was found on the floor next to her bed on her hands and knees. Page 1 of 2 145596 145596 02/09/2023 Snyder Village 1200 East Partridge Metamora, IL 61548

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/8/23 at 11:20 AM, V2 (Director of Nursing) stated investigation of R84's fall on 2/8/23, determined R84's pressure pad alerting device was not sounding when staff found R84 on the floor. V2 stated the pressure pad alerting device should be functioning at all times. 2. R25's current medical record documents R25's diagnoses to include: Dementia, Cognitive Communication Deficit, and Other Symptoms and Signs Involving Cognitive Functions and Awareness. R25's most recent Fall Risk Assessment Tool (dated 02/06/23) documents a score of 21, indicating R25 is at high risk for falls. R25's current medical record documents R25 fell at the facility on the following dates: 12/12/22, 12/19/22, 01/20/23, 02/02/23, and 02/06/23. On 02/07/23 at 08:00 AM, R25 was sitting in a wheelchair with a fall prevention alarm in place at a table in the dining room. R25 was eating breakfast, and V6 (R25's daughter) was sitting next to R25. A large hematoma was present on the left side of R25's forehead and an extensive amount of dark purple facial bruising was present on R25's forehead extending down into R25's orbit areas. R25's daughter stated she sustained the injuries after a recent fall. R25's Event Report (dated 01/20/23) documents the following: (R25) was left in the bathroom without supervision. She attempted to stand and pull pants up independently and fell to the ground. The following fall prevention intervention was implemented after R25's 01/20/23 fall and was documented on her current care plan: (R25) will not be left alone in the bathroom. On 02/08/23 at 3:15 PM, V2 (Director of Nursing) stated, (R25) should not have been left alone in the bathroom. She is a high risk for falls, has a history of multiple falls, and has poor safety awareness due to her Dementia. R25's Event Report (dated 02/02/23) documents the following: (R25) was found on the floor lying on her left side at 03:00 PM. R25's current care plan documents the following fall prevention intervention was implemented on 02/02/23 after R25's fall: Staff to ensure that chair alarm is on and functioning properly. On 02/08/23 at 3:30 PM, V2 (Director of Nursing) stated R25's fall prevention alarm was not functioning at the time of R25's fall on 02/02/23. 145596 Page 2 of 2