Health inspection·January 2, 2025

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 the interviews and record reviews, the facility failed to provide the required staff assistance for bed mobility and ambulation for dependent residents as per the MDS (Minimum Data Set) assessment. This applies to 2 of the 3 residents (R1 and R2) reviewed for resident falls and injuries in a sample of 3. The Findings Include: 1. R1 is an [AGE] year-old female admitted on the dementia floor on 8/18/22 with an admitting diagnosis, including vascular dementia and multiple sclerosis. On 12/31/24 at 9:25 AM, R1 was observed in her bed and was unable to move her lower extremities except wiggling toes. On 12/31/24 at 9:25 AM, R1 stated, I had a fall to the right side of my bed. My leg didn't move the way I want to. I don't remember what my CNA was doing at that time. A review of R1's fall risk assessment dated [DATE] document that R1 is high risk for fall. A review of the R1's ADL (Activities of Daily Living) care plan document interventions including the resident requires physical assistance by staff to turn and reposition when in bed. A review of the MDS (Minimum Data Set) dated 11/6/24 document that R1 is dependent on bed mobility requiring two or more helpers to complete the activity. A review of the reportable document that the facility reported a fall for R1 on 11/14/24 while V3 (Certified Nursing Assistant/CNA) was providing care to R1. On 12/31/24 at 10:10 AM, V3 stated, I was on orientation when I provided care to R1, and R1 had a fall on 11/14/24. On 11/14/24, I entered R1's room to prepare her for mechanical lift transfer. I was alone in R1's room. I put clothing on her and the sling under her for mechanical lift transfer. I was on her left side and turned her to the right side to tuck in the sling. R1's leg was shaky and twitchy, and her leg slid over the side of the bed, and R1 slid down on her buttocks. I was supposed to work with V7 (CNA), but V7 was out with another resident. On 12/31/24 at 11:20 AM, V7 stated, I am not sure why V3 turned R1 by herself. I told her to wait Page 1 of 2 145853 145853 01/02/2025 Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656

F 0689 for me, but she was overconfident that she could do it. Level of Harm - Minimal harm or potential for actual harm On 12/31/24 at 11:10 AM, V2 (Director of Nursing/DON) stated, During the two weeks of orientation, the new CNA (V3) works with a mentor to practice skills, learn processes, and learn the resident's habits. I don't know why V7 (CNA) wasn't there. The orientee (V3) should have worked with her mentor to prevent R1's fall. Residents Affected - Few On 12/31/24 at 10:45 AM, V8 (Restorative Nurse/RN) stated V3 was supposed to work with another staff member during orientation to practice her skills and learn about resident-specific needs. As per our MDS assessment, R1 requires two-person assistance for bed mobility. 2. R2 is an [AGE] year-old female admitted on [DATE] with an admitting diagnosis including vascular dementia, Alzheimer's disease, and psychosis. A review of R2's fall risk assessment dated [DATE] document that R2 is high risk for fall. A review of the MDS (Minimum Data Set) dated 11/14/24 document that R2 requires partial moderate assistance for ambulation. A review of R2's care plan documents R2 was care planned for her limited mobility with interventions: The resident requires physical assistance by staff to walk as necessary. A review of the reportable documents the facility reported a fall for R2 on 12/12/24 with a laceration on her right eyebrow requiring 3 stitches. On 12/31/24 at 10:55 AM, V5 (Social Service Personal) stated, R2 is unsteady when she walks, and she is supposed to be in her wheelchair with supervision as she tends to stand up abruptly. On 12/12/24, I saw R2 in her wheelchair in the activity room when I passed by the activity room. No staff was present in the activity room to supervise residents. When I was about to exit the unit, I saw her standing and coming out of the activity room and taking a few steps. R2 tumbled down face forward and hit the right side of her forehead, causing a laceration that required three stitches. After R2's fall, I was the first to come to the scene; no nurse, nursing assistant, or activity staff were in the activity room to monitor residents. On 12/31/24 at 11:10 AM, V2 stated that someone should supervise dementia residents in the activity room to prevent falls. 145853 Page 2 of 2