Health inspection·February 7, 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 follow its Transfer policy by failing to provide a two persons assist while transferring a dependent resident from bed to wheelchair. This failure affected one of three residents (R1) reviewed for accidents. This failure resulted in R1 falling from a mechanical lift to the floor and sustaining a fracture of the left superior and inferior pubic rami medially, a sacral fracture and small hematoma. Findings Include: On 2/5/25 at 10:30am, V3 (RN) stated that she provided care to R1 on the day of the fall (2/3/25) and was called to the room by V4 (CNA) after R1 slid out of the sling to the floor during transfer from the bed to the wheelchair. V3 stated that she assessed R1 and noted a cut on the left outer ear. V3 stated that 911 was called and R1 was taken to the hospital for further evaluation. On 2/5/25 at 10:20am, V5 & V9 (CNAs) both stated that R1 is a two person assist with mechanical lift. Both stated that there is a color sticker on each resident's bed which indicates the residents transfer status. V7 (RN) stated that she has provided care to R1. V7 stated that R1 is a two-person mechanical lift transfer. On 2/5/25 at 10:30am, V6 (Private Caretaker) stated that she assisted V4 (Primary CNA) in transferring R1 from bed to wheelchair, she applied the right and left sling onto the right leg and left arm. On 2/5/25 at 11:00am V4 (Primary CNA) stated that R1 requires a mechanical lift with two persons assist. V4 stated that she and V6 (Private Caregiver) applied the sling onto R1. V4 stated that she applied the upper and lower left side of the sling while V6 applied the right side. V4 stated that during the process of moving the mechanical lift the left leg came out and R1 slid out to the floor. V4 stated that this is the first incident with R1 and she has worked for 30 years in the facility. V4 stated that she provides care to R1 regularly and receives in-services once a month on mechanical lift transfer. V4 stated that each resident has a color sticker on the head of the bed which let staff know the transfer status of the resident. On 2/5/25 at 11:30am, V2 (Director of Nursing) stated that the investigation is ongoing, and she does not know how the resident fell out of the sling. V2 stated that R1 is a two person transfer with mechanical lift. V2 stated that, a plan of correction is currently ongoing, and all steps are being taken to keep residents safe during mechanical lift transfer. V2 stated that R1 has never fallen in the past, and this is the first fall incident with R1. Page 1 of 2 145683 145683 02/07/2025 Elevate Care Abington 3901 Glenview Road Glenview, IL 60025

F 0689 Level of Harm - Actual harm Residents Affected - Few On 2/6/25 9:25am, V3 (ADON) stated that she has been working in the facility for over 30 years and is familiar with R1. V3 stated that R1 is oriented to name and requires a two-person assist. V3 stated that staff can locate the resident's transfer status on the foot or head of the bed, and it is color coded. On 2/6/25 at 12:53pm, V1 (Administrator) stated that R1 is a two-person transfer with a mechanical lift. V2 stated that private caregivers are not allowed to transfer residents in the facility because they are not trained by the facility. V1 stated that he thinks staff did not check to make sure the slings were properly secured to the mechanical S-hooks which resulted in the fall. R1 is a [AGE] year-old female admitted on [DATE] with diagnosis of but not limited to ADULT FAILURE TO THRIVE, SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM, and ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE. R1's care profile reads; Hoyer lift. R1's Fall Incident document reads; Nursing Description: Nurse on duty was called to the room by the CNA. Reported the patient had slid from the side of the sling to the floor during a transfer with the lift. Predisposing Situation Factors. During Transfer R1's Morse fall scale evaluation dated 11/5/24 reads; Category: High Risk for Falling. Score: 61. G- Fall Scoring: High Risk 45 and higher. R1's MDS (Minimum Data Set), section GG-Functional Abilities dated 10/1/24 reads; E. Chair/bed-to-chair transfer: 01. Dependent-Helper does all the efforts. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the residents to complete the activity. R1's care plan dated 11/13/2024 reads, R1 presents with a functional deficit in Bed Mobility related to Physical inactivity. R1 requires use of full body lift for transfer related to activity. Intervention- Full body lift with 2 persons assist for all transfer. Hospital record titled, ED Attending Progress Note dated 2/3/25 reads; XR Hip 2 Views left and Pelvis. 1. Fracture of the left superior and inferior pubic rami medially. 2. CT shows also a left sacral fracture and small hematomas. Facility policy titled: Transfer-Manual Gait Belt and Mechanical Lifts dated 1-19-18. Purpose: To protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents. Responsibility: Licensed Nurse, CNA, Restorative, Therapy. Guidelines: Mechanical lifting device shall be used for any residents needing a two person assist, or who cannot be transferred comfortably . Facility's policies and procedures, census and fall log, were reviewed. No concerns were identified. 145683 Page 2 of 2