Health inspection·June 16, 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 observation, interview, and record review, the facility failed to use a two-person transfer with a gait belt, as shown in the EMR (Electronic Medical Record), for a resident with a history of multiple falls. This applies to 1 of 3 residents (R2) reviewed for accidents and supervision in the sample of 3. The findings include: On June 12, 2025, at 11:21 AM, V3 (CNA-Certified Nursing Assistant) transferred R2 from the wheelchair to the toilet. No other staff were present. V3 said R2 was wearing regular socks and did not have shoes. V3 tightly held R2's waist band of her pants and R2's incontinence brief to lift the resident from the wheelchair to the toilet. V3 did not use a gait belt. As V3 was attempting to stand R2, R2's knees were buckling and R2 was unable to bear her full weight as she was being transferred to the toilet. R2 was unable to follow V3's instructions due to her cognitive status. V3 said R2 needed a new incontinence brief due to R2's previous incontinence brief being torn after it was used to lift the resident during transfer. V3 obtained a new incontinence brief and instructed R2 to hold the handrail and the handle of her wheelchair. As R2 reached for the handrail, a yellow plastic wrist band was visible on R2's right wrist. V3 said when a resident is wearing a yellow wrist band, it means the resident is a high fall risk. V3 again attempted to lift R2 without using a gait belt. V3 was able to lift the resident from the toilet to a standing position. As V3 attempted to place the clean incontinence brief on R2, R2's knees began to buckle and V3 had to lower R2 back down to the toilet. A pair of shoes was in a clear bag next to R2's bed and V3 said she was not aware R2 owned shoes. V3 placed the shoes on R2's feet. V3 left R2 unattended and left the bathroom to find another CNA to help her. V3 returned to the bathroom with V6 (CNA). V3 applied a gait belt to R2. V3 and V6 completed R2's toilet hygiene, applied a new incontinence brief, and transferred R2 back to the wheelchair. V6 said the type of transfer a resident requires is shown in the EMR and each CNA should carry their own gait belt, which is a required part of a CNA's uniform. The EMR shows R2 was admitted to the facility on [DATE], with multiple diagnoses including, acute kidney failure, anxiety disorder, hypertensive heart and chronic kidney disease, gastro-esophageal reflex disease, history of falling, sensorineural hearing loss, dementia, chronic kidney disease, depression, Alzheimer's disease, benign paroxysmal, vertigo, localized edema, visual loss, history of cancer of large intestine, anemia, history of breast cancer, essential tremor, and irritable bowel syndrome. R2's MDS (Minimum Data Set) was not completed at the time of this investigation. Page 1 of 2 145874 145874 06/16/2025 Meadowbrook Manor - Naperville 720 Raymond Drive Naperville, IL 60563

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's care plan for ADL (Activities of Daily Living) self-care performance deficient, initiated on June 12, 2025, shows multiple interventions initiated on June 12, 2025, including, Transfer: Requires dependent of 2 people with transfers. The EMR shows the following special instructions for R2, Transfer code: dependent assist of 2 (mod A x 2) (Moderate Assistance with two people) stand pivot transfer. The EMR shows R2 sustained falls at the facility on June 8, 9, 10, and 11, 2025. On June 12, 2025, at 1:25 PM, V4 (Risk Management RN-Registered Nurse), said R2 has severe cognitive impairment and has impulsive behaviors. R2 is a two person transfer assist. All CNAs should use a gait belt when transferring residents. V4 continued to say the resident's transfer status is shown in the EMR and each CNA is required to know the transfer status of the resident they are caring for before transferring the resident. V4 said R2's four recent falls at the facility were due to poor safety awareness due to cognitive impairment and anxiety disorder. The facility's undated policy entitled, Resident Transfer Protocol shows: Statement of policy: It is the policy of [the facility] to attempt to protect both its residents and employees from injury in the course of transferring patients/residents. Procedure: .3. The transfer technique that is appropriate for each resident will be listed on the Special Instructions in [EMR] and a transfer code will be posted on the resident's foot board. 4. No resident is to be transferred without first verifying the transfer technique assigned to that resident to know what type of transfer is required by that resident on that day. The facility's undated policy entitled, Gait Belt Usage shows: Statement of Policy: It is the policy of the facility that all residents and staff are safe from injury during all transfers. It is the policy of this facility that a gait belt will be used when performing transfers or when ambulating a resident unless contraindicated or resident refuses. Procedure: 1. Gait belts are a part of the staff's uniform; all staff has to have individual gait belts with them during the entire shift that they are scheduled to work. 2. When transferring a resident (sit to stand, bed to chair, chair to bed, chair to toilet, toilet to chair), a gait belt must be used unless contraindicated or refused. 145874 Page 2 of 2