Health inspection·February 20, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure allegations of abuse were reported for 1 of 3 residents (R1) reviewed for abuse in the sample of 5. Residents Affected - Few The findings include: On 2/15/24 at 1:32 PM, V6, Licensed Practical Nurse (LPN), said she cared for R1 on 2/9/24. V6 said when she was giving R1 her noon medications that day, R1 told her that someone in the middle of the night grabbed her by her hair and was dragging her and calling her names and mocked her. V6 said she told V8, LPN that R1 alleged she was being dragged around on the floor by her hair in her room. V6 said V7 told her R1 had made those kinds of statements before. V6 said she would be expected to inform the administrator about any abuse allegations as soon as possible. V6 said did not report R1's abuse allegations to the Administrator. On 2/15/24 at 3:02 PM, V7, Certified Nursing Assistant (CNA), said R1 said she was trying to get out of bed at night and the night lady was yelling at her, and someone was pulling her hair, then someone said just leave her there. On 2/20/24 at 9:05 AM, V8, LPN, said if she ever heard of any allegations of abuse, she would notify V1, Administrator/Abuse Coordinator immediately because she is the abuse coordinator. V8 said if V1 was not available, she would notify the Director of Nursing (DON) or a supervisor. On 2/20/24 at 9:37 AM, V9, LPN, said if any resident reported any allegations of abuse, she would definitely call the DON, the family, and probably the police too. On 2/20/24 at 10:13 AM, V1 said when she reviewed the staff interviews, she came across one from V12, CNA, which said R1 would become confused and say night shift had dragged her by her hair, kicked her, and they don't change her. V1 said she was never informed of the allegations, or she would have done an investigation. A written interview from V12 dated 2/13 shows R1 told V12 several times that night shift has dragged her by her hair and they kick her, and they don't change her. The facility's Abuse Prevention Program Policy and Procedure (updated 7/1/22) shows employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator. Page 1 of 2 145917 145917 02/20/2024 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

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 ensure a high fall risk resident was transferred with a gait belt for 1 of 5 residents (R1) in the sample of 5 reviewed for safety. The findings include: On 2/15/24 at 1:32 PM, V6, Licensed Practical Nurse (LPN), stated on 2/9/24 around 7:30 AM, V7, Certified Nursing Assistant (CNA), came to get her and brought her to R1's room where R1 was on the floor in her bathroom. V6 stated V7 told her R1's legs went out and she had to assist R1 to the floor. V6 stated R1 did not have a gait belt on her person. On 2/15/24 at 3:02 PM, V7, CNA, stated she was caring for R1 on 2/9/24. V7 stated she took R1 to the bathroom and was pulling up R1's pants and R1's legs went out and she just collapsed. V7 stated she was able to catch R1 by her pants and lower her to the floor in the bathroom. V7 stated R1 did not have a gait belt on when she went down. On 2/20/24 at 9:05 AM, V8, LPN, stated R1 transferred with a 1-2 person assist and a gait belt. On 2/20/24 at 10:13 AM, V1, Administrator, stated they moved R1 closer to the nurse's station because she is a high fall risk and is restless at night. On 2/20/24 at 12:01 PM, V13, Physical Therapy Assistant (PTA), stated she worked with R1 on several occasions. V13 stated R1 needed someone with her at all times for transfers and she needed a gait belt. V13 state R1 was not safe without a gait belt. R1's Fall Risk assessment dated [DATE] shows R1 is a High Fall Risk. R1's current Face Sheet provided by the facility (undated), shows R1's diagnoses include, but are not limited to, muscle wasting and atrophy, syncope and collapse, diabetes, sick sinus syndrome (a group of heart rhythm problems), anxiety, anemia, cerebral infarction (stroke), and atrial fibrillation (heart arrhythmia). R1's Minimum Data Set, dated [DATE] shows R1 requires substantial/maximal assistance with toilet transfers. The facility's Bathroom, Assisting a Resident to Policy (revised February 2018) shows a gait belt should be used for safety and support. 145917 Page 2 of 2