Health inspection·July 15, 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 observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for accidents in the sample of 9. This failure resulted in R1 receiving stitches to a left leg laceration. This past noncompliance occurred from 6/3/25 to 6/9/25.The findings include: The facility's initial incident report sent to IDPH (Illinois Department of Public Health) showed R1 sustained a laceration to her left lower extremity on 6/3/25 at approximately 11:15 AM. The report showed R1 was provided first aid and orders were obtained to send R1 to the local hospital emergency department. The report showed R1 left the facility with paramedics at around 1:06 PM the same day. R1's face sheet printed on 7/10/25 showed a [AGE] year-old female admitted on [DATE]. The face sheet showed diagnoses including but not limited to heart failure, cataracts, left foot drop, hypertension, venous insufficiency, and polyneuropathy. R1's facility assessment dated [DATE] showed moderate cognitive impairment and total staff assistance for chair to bed transfers. R1's care plan showed a focus area related to ADLs (activities of daily living). Interventions included: TRANSFER: (R1) requires weight bearing physical assist (full body lift) of 2 staff participation in moving between surfaces to and from bed, chair, wheelchair, standing position. Date initiated 12/05/2023. On 7/10/25 at 9:50 AM, R1 was lying in bed and covered with a light sheet. R1 was pleasantly confused and had no recall of a leg injury or emergency room visit. V3 (Registered Nurse) entered the room and removed the sheet. R1's left lower leg was wrapped in white gauze from the mid-calf to the foot and elevated on a pillow. V3 stated she had a leg injury while being transferred from her chair to the bed. Her left leg hit the side rail of the bed. She has been a mechanical lift transfer since she was admitted . The aide called me in right away after it happened. R1 was already on the bed and her leg was bleeding. The aide was in the room alone and no one else was helping him. He was very shaken up and so sorry. I applied pressure and cleansed the open wound. The wound care nurse was notified and came right in to assess it. R1 was sent to the emergency room the same day. She had to get stitches and came back the same day. V3 said all residents requiring a mechanical lift should be done with two people. The aide (V4) is a big, tall guy and he did it by himself. V4 likely thought since R1 is so small that it wouldn't be a problem. On 7/10/25 at 10:18 AM, V4 (CNA-Certified Nurse Aide) stated he was assigned to give R1 a shower on 6/3/25. V4 said resident transfer status is posted inside the closet doors and in the care plans. V4 said R1 has always been a two person assist using a mechanical lift. V4 said he wheeled R1 into her room after the shower and got her dressed in day clothes. V4 was attempting to get the lift sling under R1 while seated in her wheelchair. V4 said he pulled on the sling to get her closer to the bed and her left leg hit the side rail. V4 said he saw it bleeding and continued to transfer her by himself onto the bed. V4 said he should have done the transfer preparation and actual transfer itself with another staff member. V4 said he was in a hurry and thought he could do it alone. V4 said it is safer with two people and Page 1 of 2 145638 145638 07/15/2025 Bella Terra Bloomingdale 165 South Bloomingdale Road Bloomingdale, IL 60108

F 0689 Level of Harm - Actual harm Residents Affected - Few ensures the resident does not hit their body on anything. It is a bad idea to do it alone. On 7/10/25 at 10:50 AM, V5 and V6 (CNAs) stated R1 has been a mechanical lift since she came here. Mechanical lifts are always done with two staff members. It is for resident safety and it's the right thing to do. It helps keep residents safe. One aide guides the legs and back while the other aide works the lift. One person can't do both if they are alone. On 7/10/25 at 12:01 PM, V2 (Director of Nurses) stated she interviewed V4 after the incident of 6/3/25. V2 said V4 was preparing R1 for a mechanical lift transfer from the chair to the bed. V4 was alone and moving R1 around to get the sling underneath her buttocks. R1's leg hit the bed side rail and was cut open. V2 said V4 did transfer R1 to the bed without another staff member. V2 stated residents should never be injured during staff cares. The correct procedure would have been to follow her care plan. R1 is a two person assist for all transfers. It is facility policy to use two staff members for every mechanical lift transfer. There is the potential for the lift to fail, injury, or dropping a resident when the policy is not followed. R1's local emergency room after visit summary report dated 6/3/25 showed a left, lower leg laceration 20 centimeters in length with blunt trauma. The report showed R1 received five internal sutures and 24 external sutures to the left leg. The facility's Mechanical Lift Transfers policy revision dated 8/16/24 states: 5. There will always be 2 staff to assist resident. 1 staff will control the lift as the other will guide resident and support back and neck to transfer surface. 15.It is also a safety issue putting back the sling under a resident who is sitting on a wheelchair or a recliner. Prior to the survey date of 7/15/25, the facility had taken the following action to correct the noncompliance:On June 3, 2025, V4 received formal one on one training on mechanical lift transfers, one-person transfers, and sit to stand transfers. On June 3, 2025, a facility wide audit was done on all [NAME] brand beds for damage. On June 3 to June 9, 2025, all certified nurse aides were in-serviced on sit to stand transfers, two person transfers, and one person transfers with competency return demonstrations. The Director of Nursing or designee will conduct randoms audits for three residents to identify any issues with staff to resident transfers. The audits will continue three times per week for 12 weeks. Any identified issues or concerns be immediately addressed. Audits started 6/5/2025, ongoing for 12 weeks. A QA meeting was held with the facility Medical Director, Facility Administrator, and Director of Nursing to review the plan of correction of 6/5/2025. 145638 Page 2 of 2