Health inspection·May 4, 2023

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 implement effective fall interventions and provide adequate supervision to one resident (R1) out of four residents (R1, R2, R3, and R4) who were reviewed for falls. This failure resulted in R1 experiencing three falls in less than one month, and one of these falls resulting in a fractured right clavicle. R1 is a [AGE] year old male who was originally admitted to the facility on [DATE] and continues to reside in the facility. R1 has multiple diagnoses including, but not limited to the following: right femur fracture, muscle weakness, unsteadiness on feet, subdural hemorrhage, HTN (Hypertension), CHF (Congestive Heart Failure), CKD III (Chronic Kidney Disease stage 3), AFib (Atrial Fibrillation), gout, vascular dementia, right clavicle fracture, history of falling, depression, and CAD (Coronary Artery Disease). Facility incident report, dated 3/11/23 at 4:20AM, states in part but not limited to the following: CNA heard bed alarm and went to check on (R1). Noted patient lying on the floor on his left side by the footboard of the bed. Patient does not remember and states, I was dreaming that I was walking. Patient complains of slight pain to right shoulder. X-ray was ordered to right shoulder and urinalysis. Patient is alert and oriented x 1-2, forgetful and confused. New interventions: evaluate medications with MD and pharmacy input, neuropsychological evaluation, and check patient frequently. Facility care plan, with initiation date of 2/16/2023, states in part but not limited to the following: Focus: R1 is at risk for falls r/t generalized weakness secondary to right hip fracture status post ORIF (open reduction and internal fixation). Goal: Will remain free of falls through next review. Interventions: Ensure that the bed is in the appropriate lowest position for the patient and that the bed is locked as appropriate, dated initiated: 2/16/23; use of personal or pressure sensor alarms when in chair or bed, date initiated: 3/4/23; patient was reeducated on using his call light for assistance, date initiated: 3/4/23; evaluate medications with MD and pharmacy input, date initiated: 3/11/23; move resident to a room with optimal visual access from the nurses station, date initiated: 3/11/23, neuropsychological evaluation, date initiated: 3/11/23, check patient every 15 minutes, date initiated: 3/11/23; staff will do frequent checks on the patient, date initiated 3/11/23. On 05/04/23 at 11:20AM, V3 (Registered Nurse) was interviewed regarding R1. V3 said, (R3) is confused and he is a high fall risk. He needs increased supervision. Page 1 of 3 145869 145869 05/04/2023 Alden Estates of Skokie 4626 Old Orchard Road Skokie, IL 60076

F 0689 On 05/05/23 at 10:05AM, V4 (Licensed Practical Nurse) was interviewed regarding R1's fall incident on 3/11/23. V4 said =he came to the facility due to a fall in which he fractured his hip. Level of Harm - Actual harm Residents Affected - Few V4 said, I was the nurse on duty when (R1) fell on 3/11/23. We found him lying on the floor by his footboard around 4:00AM. His bed alarm was going off which alerted us to his room, however, he was already on the ground. He was complaining of pain to his shoulder, so the doctor ordered an x-ray that morning. The x-ray showed him to have a fracture to his right clavicle. V4 said, (R1) is confused and forgetful and has been since admission. He does not often use his call light, and will attempt to get up on his own without calling for assistance. His room was moved closer to the nursing station after this fall to provide increased supervision. He is definitely high fall risk since he is unsteady and will get up without calling for assistance. Sometimes, I will be told that the resident is alert, but (R1) is not. It changes depending on the time of day. At 11:25AM, V6 (family member) was interviewed regarding care at the facility. V6 said her biggest concern with the facility is she feels as if they do not have enough CNAs (certified nursing assistants) and cannot provide adequate supervision, especially at night. Sometimes the call light time is really high and he (R1) has to wait a long time for assistance. (R1) gets confused at night time and tends to get up without assistance. (R1) had a fall prior to admission and came here for therapy. He was unsteady and a high fall risk even before admitting here. At 12:10 PM, V2 (Director of Nursing) was interviewed regarding R1's care and his fall incidents. V2 said R1 has had three falls while a resident here; 3/4/23, 3/11/23, and 3/29/23. V2 said, On 3/4/23, the intervention we put in place was re-education on using the call light to request assistance, adding the bed alarm, and increased supervision. Increased supervision means the staff will check on him every 15 minutes. On 3/11/23 R1 fell and sustained an injury. The interventions after 3/11/23 are we had the pharmacist review his medication and ordered a consult with a neuropsychologist. The pharmacist and neuropsychologist did not have any concerns. However, at this time they did diagnose him with dementia. This is the first time he was tested for dementia, but I believe it is not a new diagnoses. After this fall, we also moved him closer to the nursing station and we are ensuring his bed is in the lowest position. His bed was not in the lowest position when he fell on 3/11/23. V2 said, After the first fall on 3/4/23, we recognized his pattern of constantly getting up without asking for assistance. (R1's) wife comes every day, spends most of the day here, and helps provide supervision. At night time, there is less people. It is to be noted that all three fall incidents occurred at night time, and R1 was attempting to get up without assistance or supervision. Facility policy titled Management of Falls, dated 08/2020 states in part but not limited to the following: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure: 3. Develop a plan of care to include goals and interventions which address resident's 145869 Page 2 of 3 145869 05/04/2023 Alden Estates of Skokie 4626 Old Orchard Road Skokie, IL 60076

F 0689 risk factors. Level of Harm - Actual harm 7. Monitor for changes in medical condition and notify physician as necessary to manage changes in status of the resident. Residents Affected - Few 145869 Page 3 of 3