Health inspection·January 16, 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 properly transfer one resident (R1) and ensure that R1 was wearing proper footwear during the transfer. This failure resulted in R1 being hospitalized and sustaining a fracture to the neck. Findings include: R1 is an [AGE] year old female who admitted back to the facility on [DATE] and was discharged to the hospital on 1/10/2025. R1 has multiple diagnoses including but not limited to the following: type II DM, dementia, psychosis, HTN, dysphagia, difficulty in walking, unsteadiness on feet, disorientation, and need for assistance with personal care. V3's (Licensed Practical Nurse) progress note dated 1/5/2025 at 10:00AM states in part but not limited to the following: V4 (Certified Nursing Assistant) was transferring R1 from wheelchair to the shower chair. V4 said R1 began to slide and was lowered to the floor. R1 was wearing slippers at the time of transfer. On 1/15/2025 at 11:15AM, V4 said I was going to give R1 a shower. R1 was previously a resident here and I was familiar with her. However, this was the first time I had given her a shower since she returned. R1 can transfer independently. R1 was sitting in her wheelchair. I placed her walker in front of her, she stood up using the walker, and I attempted to move the wheelchair and replace it with the shower chair. During the transfer, R1 began to slip and slide down to the ground. She was wearing slippers and she seemed weaker than normal. I assisted R1 in sliding down to the ground. V4 said R1 did not need a transfer belt. A transfer belt is used when a resident cannot mobilize themself. R1 can transfer herself and only needs supervision. It is to be noted that per R1's care plan with initiation date of 12/26/2024 states in part: R1 requires substantial/maximal assistance with 1-2 person assistance to move between services. when transferring. Use gait belt with transfers. Per Minimum Data Set (MDS) dated [DATE] states in part but not limited to the following: R1 requires maximum assistance when transferring into the shower and when going from a sitting to standing position. On 1/15/2025 at 1:41PM, V2 (Director of Nursing) stated R1 required a gait belt when transferring and I would have expected V4 to use one during this transfer. R1 was also wearing her favorite red Page 1 of 2 145626 145626 01/16/2025 Generations Oakton Pavillion 1660 Oakton Place Des Plaines, IL 60018

F 0689 slippers which are not appropriate when transferring. R1 should have had non-skid socks on. Level of Harm - Actual harm Hospital records dated 1/10/2025 state in part but not limited to the following: R1 presenting to the emergency room after a witnessed mechanical fall. It is reported that the fall occurred while R1 was taking a shower. R1 was guided to the ground by nursing staff and V5 (family member) observed bruising today on the back of R1's head. CT impression shows an acute C7 spinous process fracture. Residents Affected - Few On 1/16/2025 at 11:15AM, V7 (Primary Physician) said this type of fracture can occur from any sudden movement or a fall especially in the elderly. Fall Prevention and Management Policy with last review dated of 02/2023 states in part but not limited to the following: The purpose of this policy is to support the prevention of falls by implementation of a preventive program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. The falls prevention and management program is designed to assist staff in providing individualized, person-centered care. 145626 Page 2 of 2