Health inspection·June 13, 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 interview and record review, the facility failed to provide appropriate adaptive equipment during transfer of a resident which resulted with the resident falling and sustaining a bruise and an abrasion on the resident's knees. This failure affected 1 (R1) resident reviewed for use of adaptive equipment in the total sample of 5 residents. Findings include: R1's (06/05/2024) Fall documented, in part Staff notified nurse that the resident is on the floor in the shower room. Immediate Action Taken. Description: Body assessment done(,) noted with small superficial abrasion to left knee, no bleeding and small bruise to right knee. Notes. 6/6/2024. (R1) is dependent on transfer with (mechanical lift). (R1) has history of falling. On 6/5/2024, CNA (certified nursing assistant). was going to give a shower to the resident, resident was standing up holding on to the side rails in the shower room and going to transfer to the shower chair, resident(')s legs gave in and was assisted to the floor by the CNA. Head to toe assessment, noted with small abrasion to left knee and a small bruise to right knee. Intervention: (Mechanical lift) to be utilized for all transfer. On 06/12/2024 at 11:10am, with V5 (Licensed Practice Nurse/LPN) R1 was noted with a quarter size reddish purplish discoloration on the right knee and about a penny size scabbing on the left knee. R1 stated I (R1) fell. On 06/12/2024 at 2:14pm, with V12 (CNA), R1 stated there was no sling on the wheelchair. There was no sling on my chair on that day because (V17 CNA), put me on the wheelchair without using the mechanical lift. I (R1) was by the nurse's station close to the dining room around 3:00pm and the CNA (V11) took me (R1) to the shower room. I (R1) was about to sit on the shower chair, and I (R1) fell. On 06/12/2024 at 2:17pm inside the 3rd floor's shower room with V12, R1 stated the CNA (V11) told me (R1) to hold on to the grab bar, she (V11) pulled me up while she (V11) was behind me, she (V11) took the wheelchair off me (R1) and I (R1) fell. On 06/12/2024 at 1:10pm, V4 (Registered Nurse) stated it happened during the morning shift, after lunch. She (R1) was seated by the nurses station on the wheelchair and I (V4) told the CNA (V11) that she (R1) needed a shower. I (V4) was with another resident when (V6 -LPN) told me (V4) that (R1) fell in the shower. When I (V4) got to the shower room, the CNA (V11) was leaning against the wall and (R1) was seated on (V11)'s lap. There was no mechanical lift sling on the floor and on the shower chair. I (V4) think she (V11) transferred (R1) from the wheelchair to the shower chair without using Page 1 of 3 145888 145888 06/13/2024 Alden Estates of Northmoor 5831 North Northwest Highway Chicago, IL 60631

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a mechanical lift. At the beginning of the shift, I (V4) gave a 'roster' to the CNA (V11). The 'roster' will tell how a resident transfers from bed to wheelchair, wheelchair to bed, wheelchair to the shower chair and the shower chair to the bed. I (V4) would contribute her (R1) being on the floor due to weakness on the knees and not using the mechanical lift and the CNA (V11) not using her (V11) judgment in transferring (R1). On 06/12/2024 at 1:36pm, V4 stated after the incident she (V11) told me (V4) she's (R1) a (mechanical) lift! she (R1) can't stand up! The tone of voice as if she (V11) was surprised and as if she (V11) was asking me why you (V4) did not tell me (V11) she (R1) is a mechanical lift and that she (R1) can't stand up on her (R1) own. I (V4) told her (V11) 'but she (R1) can stand up and she (R1) was walking earlier with the restorative.' On 06/12/2024 at 11:53am, V7 (Restorative Nurse) stated a mechanical lift is a device being used by the staff to transfer residents from bed to chair, chair to bed, bed to shower chair and shower chair to bed. On 06/12/2024 at 11:54am, surveyor requested V7 to read R1's Restorative assessment dated [DATE]. V7 stated on the 'Adaptive Equipment use' it means staff are supposed to use mechanical lift to transfer resident from bed to chair and chair to bed, bed to shower chair and shower chair to bed. The expectation of the staff is to use the mechanical lift with all transfers. On 06/12/2024 at 12:01pm, V7 stated the importance of using the mechanical lift is for the safety of the resident because we (facility) don't want them to fall. We have a 'ROOM ROSTER' sheet with the resident's name, room number and their transfer status. We update it only if there is a change in room number, or any changes. We (facility) started using the 'roster' in June of 2023. Her (R1) name was already included and that her (R1) transfer was with a mechancial lift. Back then, she (R1) is already a mechanical lift with transfer. On 06/13/2024 at 10:37am, V16 (PT-Physical Therapist/Rehab Director) stated during the morning medicare meeting, I (V16) relayed to the department heads her (R1)'s transfer status. My (V16) recommendation was mechanical lift for all transfers and that's what was written in the 'roster'. I (V16) recommended the mechanical lift and it was written in the roster and it should be followed across the board by staff whether regular staff or not regular staff. There is a potential risk of jeopardizing the health of the resident and staff if staff will not follow the recommendation on the 'Roster'. On 06/13/2024 at 10:55am, V16 handed R1's PT (Physical Therapy) evaluation and stated she (R1) is total dependence without attempt to initiate. It means she (R1) is not helping with transfer at the time of evaluation. Since she (R1) is dependent, I (V16) told the department heads that she (R1) is a mechanical lift for all transfers. And that is how it was updated on the roster, transfer with a mechanical lift. R1 admission Record documented, in part Diagnoses: (include but not limited to) history of falling, morbid obesity, lack of coordination and unsteadiness on feet. R1's (05/07/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 14. Indicating R1's mental status as cognitively intact. R1's (5/6/2024-7/4/2024) Physical Therapy Evaluation and Plan of Treatment documented, in part Stand Pivot. Baseline Total Dependence w/o (without) attempts to initiate. 145888 Page 2 of 3 145888 06/13/2024 Alden Estates of Northmoor 5831 North Northwest Highway Chicago, IL 60631

F 0689 R1's (05/07/2024) Restorative Nursing Assessment documented, in part Adaptive ADL Equipment Used: check mark on Mechanical Lift. Level of Harm - Minimal harm or potential for actual harm R1's (12/15/22) Fall Risk Assessment documented, in part Score: 9. Category: At risk. Residents Affected - Few R1's (06/05/2024) Fall risk Assessment documented, in part Score: 9. Category: At risk. V11's (6/6/24) statement documented, in part I (V11) was the assigned CNA for (R1) on 6/5/24. I (V11) asked the nurse how the resident transfer because she (R1) was due to have a shower today. Nurse gave me a copy of the resident roster in the morning when my (V11) shift started. When I (V11) went to take her (R1) to the shower room, she(R1) stood up and was holding on the siderails (grab bar) in the shower room, when I (V11) was about to have her (R1) sit on the shower chair, her (R1) legs gave in and I (V11) assisted her (R1) to sit in the floor. When CNA asked why she (V11) did not use a mechanical lift she (V11) was unable to answer. R1's (06/05/2024) Post Occurrence Documentation documented, in part Staff notified nurse that the resident is on the floor in the shower room, noted resident on the CNA assigned on the floor with both her knees on the floor. The CNA was holding on to the resident and the resident was on the CNAs lap/legs. 3 Facility staff assisted resident back on the shower chair. Body assessment done resident noted with small superficial abrasion to left knee, no bleeding and small bruise to right knee. R1's (Target date: 08/19/2024) care plan documented, in part (Mechanical) lift to be utilized for all transfer. The (undated) Room Roster - 3rd floor documented, in part R1- TRANSFER STATUS: (MECHANICAL) LIFT. The (03/2023) certified nursing assistant job description documented, in part Job Summary. Provides residents with daily nursing care in accordance with current federal, state, and local standards, guidelines and regulations, facility policies and as may be directed by the charge nurse, supervisor, assistant director of nursing, director of nursing or administrator to ensure that the highest degree of quality care is maintained at all times. II. Qualifications H. Must possess the ability to make independent decision when circumstances warrant such action. IV. Essential functions: M. Participates in and receives the nursing report upon reporting for duty. The (08/2020) MANAGEMENT OF FALLS documented, in part Policy: The facility will assess hazards and risk, develop a plan of care to address hazards and risk, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risk for fall incidents and/ or injuries to the resident. PROCEDURE: 4. Provide assistive device for mobility as appropriate for the resident. The (01/14/2021) Total Mechanical Lift documented, in part purpose: 1. To lift, transfer and move a resident from one surface to another. Procedure: 3. Place sling evenly under client. 11. The sling remains in place under the resident and is reattached to the frame when the resident is moved back. 145888 Page 3 of 3