Health inspection·May 2, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their safe lifting and moving of patient's policy and use appropriate techniques when turning and repositioning a resident to prevent an avoidable accident for 1 of 3 residents (R1). This failure resulted in R1 sliding out of bed during care sustaining a rug burn to the left knee. Findings include: R1 face sheet shows R1 has diagnosis of hemiplegia following cerebral infraction affecting left non dominate side, and neuromuscular dysfunction of bladder. R1 MDS dated [DATE] denotes in-part that R1 requires extensive assist with 2 plus person physical assist with bed mobility. R1 physical therapy plan of care initial assessments denote R1 has contractures, decrease in strength, reduced balance, and increased need for assistance from others. On 4/28/23 at 9:28am V1 (R1 Family) said his brother who is the power of attorney informed him that the facility told him that R1 scraped her knee on something, V1 said his brother did not give him any details. V1 said when he visited with R1, R1 he observed R1 with a bandage on her left knee, V1 said he did not see a bruise. V1 said he did not ask anyone at the facility about what happened to R1's knee, V1 said he did not look under the bandage. V1 said he just want to make sure that R1 is okay at the facility. Facility incident report dated 4/23/23 denotes in-part CNA (certified nursing assistant) call for help, found resident on the floor on her back in lying position. According to CNA, while she was changing resident, resident was rolling off the bed CNA caught her and gently placed her on the floor. Resident with skin tear on left knee. No change on ROM (range of motion) of extremities. R1 progress notes dated 4/23/25 denotes family and physician notified of incident. Review of R1 progress notes and incident report there is no documentation of large bruise to R1 left knee. On 4/28/23 at 10:30am R1 observed resting in bed, awake, alert, response to communications with nodding her head yes, and no. R1 bed noted with a right-side rail in place. R1 able to follow directives. R1 observed resting on air mattress, R1 able to follow redirections, R1 nodded her head up and down when asked if surveyor could look at her skin, R1 pointed to the nurse and the nurse asked R1 was it okay and R1 nodded her head in the up and down motion. R1 left knee was noted with a border gauze, and xeroform treatment under the border gauze, R1 has an oval shape pinkish area to the left knee, there is no bleeding noted, no drainage noted, no odor noted. R1 was asked if she fall, R1 nodded her head in the up and down motion. Surveyor pointed to the floor and asked R1 if she fell on the Page 1 of 3 145731 145731 05/02/2023 Citadel at Saint Benedict 6930 West Touhy Avenue Niles, IL 60714

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few floor, R1 again nodded her head in the up and down motion. The nurse placed the dressing back on R1's knee. R1 was thanked for her time and observation. On 4/28/23 at 10:42am V2 (Nurse) said she was the nurse on duty when R1 was assisted to the floor by the CNA. V2 said V3 (CNA- certified nursing aide) informed her that she was changing R1 (providing incontinent care), and she turned R1, and R1 began to slide out of the bed, and so she assisted R1 to the floor. V2 said when she went to the room to assess R1 she noticed R1 with a skin tear to the left knee. V2 said she don't know what R1 hit her knee on to cause the skin tear. V2 said after assessing R1, R1 was lifted with a bed sheet and placed back in the bed. V2 said the physician and family was notified and orders were given. On 4/28/23 at 11:07am V3 (CNA-certified nursing assistant) said she was an agency CNA staff, and she was responsible for R1 care on 4/23/23 (morning shift). V3 said she had provided incontinence care to R1, and she was changing the sheet on the bed when R1 began to slide out the bed. V3 said she assisted R1 to the floor. V3 said R1 was in the middle of the bed when she turned R1 to the left (away from the wall and bed rail) to change the sheet. V3 said she was standing on the left side of the bed also. V3 said R1 has a new mattress, and it has bumps in it (air mattress) and that's why R1 was sliding. V3 said R1 began to slide, and her instincts was to catch R1 and bring R1 to the floor. V3 said the best thing was to gently bring R1 to the floor. V3 said she saw the abrasion to R1 left knee and she really believe it came from the carpet when she lowered R1 to the floor, but she can't be 100% certain. V3 said she was the only person assisting R1 at that time with incontinent care and bed mobility. V3 said she got report that R1 needed extensive assist, but no one informed her of how many physical assist that R1 needed. On 5/1/23 at 11:35am V4 (restorative nurse) said when turning R1 the staff should inform the resident that care is going to be provided inform R1 that she will be asked to assist with the turn by holding the assistive devices if she can. V4 said because R1 legs are contracted, R1 legs should be adjusted for comfort and to allow for the turning. R1 should be cued to assist as appropriate, ensure that R1 is in the middle of the bed initially, then pull R1 body to the opposite side of the turn, use the bed pad to assist with the turn (hold the bed pad near bottom and near back of patient), lift and push simultaneously to turn R1 onto the side. V4 said R1 has assistive devices used for bed mobility. V4 said R1 require extensive assist with 1-to-2-person physical assist with bed mobility. V4 said the staff has been in-serviced. On 5/1/23 at 3:25pm V7 (therapist) said R1 needs 2-person physical assist with bed mobility for turning and repositioning this is for safety, and this is because of the incident. V7 said the goal is for R1 to have one person assist with bed mobility. V7 said part of what therapy does is care giver education and so today he demonstrated to the facility on how to turn and reposition R1 with one-person physical assist. On 5/1/23 at 11:30am V5 (Administrator) said V3 has not being back to the facility to be in-serviced on facility practices, however all other CNA has been in-serviced. V5 said the facility has identified the root cause analysis was the position of R1 when R1 was being turned, V5 said R1 care plan has been updated, the air mattress is in place as a preventive measure for skin integrity. V5 said R1 family did receive an update on the incident. R1 MDS dated [DATE] denotes in-part that R1 requires extensive assist with 2 plus person physical assist with bed mobility. 145731 Page 2 of 3 145731 05/02/2023 Citadel at Saint Benedict 6930 West Touhy Avenue Niles, IL 60714

F 0689 Level of Harm - Minimal harm or potential for actual harm Facility CNA competency assessment, make occupied bed denotes in-part identify patient (safety) greet patient, explain procedures; provide privacy (residents rights), place bed in appropriate position, position resident on one side of the bed, utilize assist device if applicable, tuck dirty linen on first side, reposition resident to other side, remove soiled linen and complete tucking in bottom linen and dispose soiled linen, reposition resident to comfortable position. Residents Affected - Few Facility policy titled safe lifting and moving of patients, with last approve date of 01/2022 denotes in-part in order to protect the safety and well being of associates and residents, and to promote quality care, this community uses appropriate techniques and devices to lift and move residents. 145731 Page 3 of 3