Inspection·August 12, 2024

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 utilize a gait belt during resident transfer, from toilet to wheelchair, for one of three residents (R1) reviewed for falls. This failure resulted in R1 falling and sustaining a left femur fracture. Findings include: Facility's incident report (Final of 7.13.2024) R1 is a [AGE] year-old on 8/13/2021. Diagnoses include Acute Systolic Congestive Heart Failure, Overactive Bladder, Hypertension, Anemia, Anxiety Disorder, Hyperlipidemia, Alzheimer Disease, Dementia Without Psychotic Disturbance, Legally Blind, and Polyarthritis. Patient is alert and oriented x3. Patient is legally blind and requires supervision with toileting/hygiene care, transfers, bed mobility, and ambulation with a rollator walker. Patient also utilizes a wheelchair for mobility as well. Patient is continent of both bladder and bowel. Patient was assisted to the bathroom on 7/8/24 by the nursing assistant with the use of a wheelchair. After the patient finished toileting and providing hygiene care to herself, she proceeded to wash her hands at the sink in the bathroom. The nursing assistant was standing in the doorway of the bathroom with the wheelchair and gave directions to the patient to stand up from the toilet seat and to take a step forward towards the sink, when all of a sudden patient got up and had a missed step while approaching the sink in front of her. There was a change in plane and patient fell onto her knees and then the patient leaned towards her left side resting her upper body against the wall. The nursing assistant informed the nurse. Patient was sent to the hospital via 911. According to hospital records patient sustained a left femur fracture and underwent a ORIF (Open Reduction Internal Fixation) of left femur on 7/10/24. R1's MDS (Minimum Data Set of 5/10/2024) documents R1 is severely visually impaired and is cognitively intact. R1's X-ray of hip (7/9/2024) documents: Comminuted fracture involving the distal femur which appears to extend to the articular surface distally is noted. 8/10/2024 at 9:53 AM, V9 (R1's son) said via telephone, R1 has had multiple falls; two within the last 30 days. R1 called V9, screaming in pain and told him she fell. V9 said R1 sustained a femur fracture. V9 said R1 is blind and would have never attempted to go to the bathroom on her own. 8/10/2024 at 2:57 PM R1 awake/alert sitting up in bed eating pizza. Appears neat/clean. Surveyor asked R1 about her recent fall (7/8/2024). R1 said. I thought someone was with me (in the bathroom). Someone should be with me when I'm in the bathroom, I'm blind. I don't know if anyone helped me to (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145844 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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)