Health inspection·November 14, 2024

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 interviews and record review, the facility failed to ensure that one resident (R1) with a known history of falls did not have nine repeated falls. This failure affected one of four residents reviewed for falls. Findings include: R1 is [AGE] year old with diagnosis including but not limited to: Repeated falls, unspecified dementia, unspecified psychosis, muscle weakness and other specified disorders of the brain. R1's BIMS (Brief Interview of Mental Status) score is 4, indicating severe cognitive impairment. During investigation on 11/13/24 at 10:50 AM, Surveyor observed R1 sitting in a wheelchair in the dining room engaging in activities with peers and V3 activity aide. V3 (Activity Aide) said R1 usually sits near her (V3) because he often tries to get up from his chair and is a high fall risk. V3 (Activity Aide) said that R1's scar was a result of his fall on 09/28/24. Surveyor inquired about R1's fall on 9/28/24. R1 was unable to recall falling on 9/28/24 but said that he recalled hitting his head. Surveyor noted scare tissue on the back of R1's head. Surveyor inquired about R1's fall interventions. On 11/14/24 at 2:15 PM, V2 (DON/Director of Nursing) said, In the beginning, R1 had a 1:1 aide due to his behavior. He had to adjust to the facility. We tried different interventions to keep him busy because he is confused and insists that he has to go to work. If you sit with him, he (R1) likes that because he likes to talk and have company. Although R1 still was trying to climb out of the bed, he had no falls with the 1:1 aide. I had a 1:1 for 24 hours of the day for him and took the 1:1 aide away after two weeks, because the 1:1 is a CNA (Certified Nurse Assistant) that I took off of the floor. First, I removed the 1:1 aide for just one shift, then eventually removed the aide altogether. On 11/14/24 at 2:15 PM, V2 (DON/Director of Nursing) said R1 could benefit from an aide because he (R1) did not have any fall incidents with an aide. R1's Fall Assessments with the following dates: 9/26/24, 9/27/24, 9/28/24, 10/16/24, 10/20/24, 10/23/24, 10/27/24, 10/31/24, 11/03/24, and 11/08/24, all document that R1 is a high fall risk. R1's Care plan documents, R1 is at risk for falls related to impaired mobility, gait/ balance problems, activity intolerance, disease process, poor toileting habits; R1 has a history of falls and had Page 1 of 2 145844 145844 11/14/2024 Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

F 0689 a fall at the hospital prior to admission to the nursing home. Level of Harm - Minimal harm or potential for actual harm Facility report titled Incidents by incident type dated 11/13/2024 documents a total of nine fall incidents for R1 on the following dates: 9/27/2024, 9/28/2024, 10/16/2024, 10/20/3034, 10/23/2024, 10/27/2024, 10/31/2024, 11/3/2024 and 11/8/2024. Residents Affected - Few Facility report titled State Report documents, date of incident: 09/28/2024; R1 observed on the floor mat holding the back of his head. R1 has a laceration on the right side of the occipital region and is bleeding. Pressure dressing applied and R1 went to hospital 911. emergency room report dated 09/28/2024 documents, R1 presents with a fall; R1 has three centimeter scalp laceration on the right temporal portion; laceration repaired with eight staples. Facility Fall policy documents, the facility is committed to its duty of care to the residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. 145844 Page 2 of 2