Inspection·September 3, 2023

F 0689 incident and sustained a skin tear to his right arm, but V5 was unable to assess (R1) fully as paramedics in room (R!) on to stretcher. Note continued with, (R1) denies pain, but was requesting to go to hospital. Level of Harm - Actual harm Residents Affected - Few R1's hospital records, printed on 08/25/2023, indicated while in hospital, R1 had two unsuccessful attempts at a closed reduction to his right hip and had an open reduction procedure to his right hip with orthopedics on 08/11/2023. On 09/01/2023 at 11:32 AM, R1 said on day of his fall incident, I fell. R1 then said a male staff member, V4, was helping him get into bed, when he began slipping out of his arms, and almost fell to the floor. R1 added he kept slipping and sliding out from the male aide's (V4) hold, was face down when his hands went down to the floor. R1 then said the male aide, V4, was trying to hold the rest of his (R1) body up, but eventually his whole body ended up on the floor. R1 added he had pain all over, and he (V4) could not get me up from the floor, so the paramedics came and took me to the hospital. On 09/01/2023 at 2:44 PM, V4 (Certified Nursing Assistant/CNA) said as far as he knew, R1 was a two-person assist for transfers in and out of bed but to provide care; it was okay with one person. V4 then said while providing care to R1 on day of incident (08/08/2023), he used the turning pad underneath R1; pulled it towards him to turn R1 onto his side. V4 added after he had turned R1 onto his side, he noticed that the resident was a little too close to the edge of the bed. V4 (CNA) said R1 became anxious because he was on the edge, and he was unable to calm him when his legs then went over the side of the bed. V4 added he tried to hold on to R1 from the opposite side of bed, but was unable to, and R1 then slid out of bed to the floor onto his knees while he was holding on to the side rail with his arms. V4 then went over to R1's side (right side) of the bed, and tried to hold his upper body up so that R1 would not completely go onto the floor. He added R1's call light wasn't working, so he walked over to the other bed and pressed the call light, and when he returned to R1's side, he was face down on the floor and was hollering. V4 said he didn't notice any injury to R1 other than bleeding from his right arm. After the nurse (V5) assessed R1, he and another aide used the mechanical lift to get R1 off the floor and back onto bed, while the nurse left to make phone calls, then returned approximately ten minutes later and said R1 was being transferred out. V4 (CNA) did not indicate if the nurse (V5) assessed R1's range of motion to his lower extremities and whether they could move R1. When asked why he didn't initially reposition R1 away from the edge of the bed when he saw that R1 was close to the edge, V5 said I don't know, I should have repositioned him, but everything just happened so fast. On 09/01/2023 at 3:01 PM, V5 (Registered Nurse) said on day of incident at approximately 6:30 AM, V4 (CNA) was providing care to R1, when he came out of the room, informed another aide (V8), who informed her R1 was on the floor. When she walked into R1's room, she observed the bed to be waist level high, and R1 was face down on the right side of bed on the floor between the bed and wall. V5 saw blood on the floor, then asked R1 if he had hit his head. She indicated R1 said no, but it looked like he did in her opinion, so she left the room due to observing the blood, and R1 didn't complain of any new pain. When asked if she assessed R1's range of motion to lower extremities, V5 said it was communicated to her R1 was sitting on the floor, but that was not how she observed R1 to be, and she knew that R1 needed to be transferred out to the hospital emergently. V5 said after calling 911 along with R1's physician and family, she went back to his room, and R1 was in bed. V5 said she did not verbally instruct the aides to transfer R1 from the floor back into to bed. She added R1 did not complain of any hip pain, just the chronic pain to his right heel, which he had received scheduled pain medication for at approximately 6:00 AM. V5 added she didn't recall when the last fall in-service (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145827 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE British Home, The 8700 West 31st Street Brookfield, IL 60513 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 was, and a resident's level of care is communicated during shift to shift report that is done by both nurses and aides. Level of Harm - Actual harm Residents Affected - Few Reviewed first floor report sheet provided by V2 (Assistant Director of Nursing/ADON) indicated R1 is a assist of one, with activities of daily living and bed mobility which is documented within his Minimum Data Set (MDS) Section G-functional status.as a two-person physical assist. On 09/02/2023 at 10:26 AM, V2 (Assistant Director of Nursing) said her expectations for nursing post fall is for a staff member to stay with the resident to prevent further injury, and for the nurse to do a full head to toe assessment to determine level of injury and if resident requires further evaluation. The aides are not to move the resident until the nurse completes an assessment and determines whether there is any injury or not. Staff should refer to a resident's chart regarding their level of care and assistance. On 09/02/2023 at 12:40 PM, V8 (Certified Nursing Assistant) said while leaving another resident's room, she saw R1's call light on and V4 (CNA) standing in R1's doorway saying he needed something, but she couldn't hear what it was. She added while heading towards R1's room, V4 began walking towards her and said, (R1) is on the floor. V4 then said when she entered R1's room, R1 was in between the bed and the radiator almost in a fetal position, saying please help me. She saw some blood on the floor, but was unsure where it came from. V8 then left the room and went to get the nurse (V5). Upon entering R1's room, the nurse began looking for injury and asking him questions, but said she did not personally see the nurse assess R1's range of motion because she was moving things about room out of the way. After the nurse left to make the phone calls, R1 was asking to get off the floor, so V4 got the mechanical lift and they got R1 up off the floor. V8 added the nurse (V5) did not directly instruct them to get R1 up. When asked when the last in-service on fall policy and procedures was that she had attended, V8 (CNA) said they are frequent and mandatory; believes the last one was a week ago, but she does not recall when the last in-service was prior to R1's fall. Reviewed bed mobility policy labeled turning resident on side away from you last revised October 2010 that reads: Purpose: provide comfort to the resident, to prevent skin irritation and breakdown, and to promote good body alignment. Preparation: review the resident's care plan to assess for any special needs of the resident Steps in the procedure: 5. slide both your arms under the resident's back to his/her far shoulder. 6. slide the resident's shoulders toward you on your arms. 7. slide both your arms under the resident's buttocks. 8. slide the resident's buttocks toward you. 9. slide both arms under the resident's feet and ankles. 10. slide the resident's feet toward you. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145827 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE British Home, The 8700 West 31st Street Brookfield, IL 60513 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 11. cross the resident's arms over his/her chest. Level of Harm - Actual harm 12. cross the resident's leg nearest you over the leg farthest from you. Residents Affected - Few 15. place one hand on the resident's shoulder nearest you. 16. place your second hand under the resident's buttocks. 17. gently turn the resident away from you Reviewed fall-clinical protocol policy, revised March 2018, that reads: Assessment and Recognition: 2. the nurse shall assess and document/report the following: a. vital signs c. musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. e. neurological status Reviewed fall prevention in-service agenda and attendance logs that showed V4 (CNA) attended on 07/23/2023 and 08/24/2023.V8 (CNA) attended on 08/24/2023. V5 (RN) was not listed on either attendance logs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145827 If continuation sheet Page 4 of 4