Health inspection·October 9, 2025

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 observation, interview, and record review the facility failed to perform a safe wheelchair transport for a high fall risk resident for 1 of 3 residents (R1) reviewed for safety in the sample of 4. This failure resulted in R1 falling forward from the wheelchair and sustaining a broken nose and a laceration to his forehead that required sutures.Findings Include:On 10/9/25 at 10:10 AM, V9 (Certified Nursing Assistant -CNA/Restorative Aide) pushed R1 in his wheelchair from the dining room to a seating room without footrests in place. R1's shoes came in contact with the floor four times during the transport of approximately 25 feet. R1 was well groomed with a bandage on the middle of his forehead. R1 had a privacy bag for his indwelling catheter directly under the seat of his chair. The surveyor asked R1 how he hurt his head. R1 replied, He (V6 - CNA) was giving me a ride from the dining room to my room and suddenly this (touching his wheelchair) stopped, and I kept going. I hit my head on the floor. The surveyor asked R1 if he had footrests on his wheelchair. R1 said there were footrests, but they haven't used them on his chair in a while. R1 said he usually tries to pick up his feet, but the footrests do keep his feet from hitting the floor. R1 said his feet might have fallen and that could have stopped the chair. R1 denied refusing footrests to be placed on his wheelchair when staff propel him.R1's Face sheet dated 10/9/25 showed diagnoses to include, but not limited to diabetes; asthma; neuromuscular dysfunction of the bladder; dysphagia (difficulty swallowing); dementia; CHF (congestive heart failure); anemia; CKD (chronic kidney disease - Stage 3); muscle wasting and atrophy; abnormalities of gait and mobility; need for assistance with personal care; atrial fibrillation; and generalized osteoarthritis. R1's facility assessment dated [DATE] showed he was cognitively intact. R1's Final Incident Report dated 10/8/25 showed, on 10/5/25 at approximately 8:30 PM, a CNA (V6) was transporting R1 back to his room, in his wheelchair. R1 appeared to reach down for an item, which caused a forward shift in weight resulting in a fall from the wheelchair, striking his face on the floor. R1 sustained a laceration to his forehead and was bleeding from his nose. R1 was transferred to the hospital and returned to the facility on [DATE], following an overnight stay. R1 had sutures to the laceration on his forehead and had mild swelling and discoloration of the nose when he returned. R1's hospital evaluation revealed an acute nasal bone fracture with no intervention required and a laceration repaired with sutures to his forehead. This report showed that Nursing and CNAs were re-educated on safe transport procedures.R1's Fall Risk assessment dated [DATE] showed he was a high fall risk.R1's Fall Risk Care Plan updated 10/8/25 showed on 10/5/25 while CNA attempting to propel wheelchair, R1 reach for supposed item off the floor and fell out of wheelchair. R1's EMR (Electronic Medical Record) did not show that R1 had refused use of footrests on his wheelchair when being propelled by staff. R1's Hospital Records dated 10/6/25 showed R1 fell out of his wheelchair and fell on his face. R1 had a nosebleed and forehead laceration that was sutured in the emergency department. R1's (CT/Computed Tomography) of his brain/cervical spine/facial bone showed he had an Page 1 of 3 145917 145917 10/09/2025 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0689 Level of Harm - Actual harm Residents Affected - Few acute on chronic nasal bone fractures and the potential for SDH (Subdural Hematoma), therefore R1 was admitted to the Neuro ICU (Intensive Care Unit) stepdown for observation and repeat CT.On 10/9/25 at 9:28 AM, V4 (Registered Nurse - RN) said she was working 10/5/25 when R1 fell from his wheelchair. V4 said she didn't witness the fall because she was administering medications to another resident. V4 said V5 (Agency Licensed Practical Nurse - LPN) notified her of the fall. V4 said when she went to the dining room, R1 was lying on the floor bleeding from his forehead and nose. V4 said V5 had a towel on R1's forehead to stop the bleeding and V6 (CNA) was obtaining vital signs. V4 said she called 911 and R1 was sent to the hospital. V4 said R1 returned to the facility on [DATE] with a broken nose and sutures to his forehead. V4 said V6 (CNA) reported that R1 was reaching for something on the floor and fell. V4 stated, It was so strange because I've never seen him (R1) reach for anything like that. V4 said V6 (CNA) said he was going to get R1 to bed, and he fell right in front of him. I'm not sure exactly how that happened. V4 said R1 was alert and oriented and was able to make his needs known. V4 said R1 would be able to tell you what happened. V4 said R1 usually had good trunk control when he was sitting up in the wheelchair and normally asks for assistance and she was so surprised by the fall. On 10/9/25 at 10:45 AM, V5 (Agency LPN) said she was preparing meds when she heard a loud sound, as if someone fell and she heard R1 scream. V5 said she ran to the dining room and R1 was face down on the floor and V6 (CNA) was there. V5 said R1 was bleeding from his nose and forehead. V5 said she noticed R1's catheter was trapped under his leg and assumed the resident may have been trying to get the catheter out, when he fell forward. V5 said V6 (CNA) told her that R1 was reaching for something.On 10/9/25 at 11:15 AM, V7 (CNA) said he was working 10/5/25, but did not witness R1's fall. V7 said he was assisting another resident and noticed the ambulance lights. V7 said he went to the dining room and saw R1 on the floor. V7 said he's familiar with R1 and he was alert, oriented, and was able to let the staff know what he needs. V7 said he had never seen R1 reach down from the wheelchair, especially when staff were pushing him. V7 stated, To be honest with you, I don't think he was trying to reach over for something. If someone was pushing him, then why would he try to pick something up? V7 said V6 told him he didn't know what happened. V7 said V6 told him he was pushing R1 and all the sudden R1 was falling forward. On 10/9/25 at 1:40 PM, V6 (CNA) said he was working on 10/5/25 and around 8:40 PM he went to get R1 ready for bed. V6 said R1 gathered his puzzle book and glasses case with pens inside. V6 said he released R1's brakes and started pushing R1's wheelchair. V6 said he turned R1 from the table and pushed the wheelchair 3-4 feet from the table when suddenly it looked like R1 was reaching down for something on the floor. V6 said R1 fell from the wheelchair and landed face first. V6 said R1 had no reason to reach, it didn't make sense. V6 said R1 never had footrests on his wheelchair. V6 said we push R1's wheelchair and he always lifts up his feet. V6 said there was nothing in front of us that would have blocked the wheels. V6 said he was holding the chair and R1 just went all the way forward. V6 said he doesn't know if R1 would have fallen if the foot pedals were in place. V6 said R1 still could have fall because he was reaching. V6 said the staff try to use foot pedals on resident's wheelchairs just in case they can't lift their feet because they could get tired, and their feet could fall down. On 10/9/25 at 12:18 PM, V3 (Director of Nursing - DON) said she was notified by V4 (RN) on 10/5/25 that V6 (CNA) was in the process of moving R1 in his wheelchair when R1 reached for something and fell. V3 said R1 was hospitalized 24-30 hours and had sustained broken nose and sutures to a forehead laceration from the fall. V3 said whenever staff are propelling a resident in the wheelchair, they should be using footrests. V3 said this was an important safety measure because feet can get stuck, and accidents can happen. The surveyor asked V3 if R1 had footrests for his wheelchair. At 12:32 PM, V3 walked to the dining room. R1 was 145917 Page 2 of 3 145917 10/09/2025 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0689 Level of Harm - Actual harm Residents Affected - Few seated in his wheelchair at the table and there were no footrests in place. V3 asked V9 (CNA/Restorative Aide) and V9 said R1 refuses the footrests. V3 went to R1's room and there were two footrests on a table and one footrest in the closet. V3 said she wasn't sure if the footrests were for R1's wheelchair. V3 stated, I'd like to think if he was refusing footrests that we would have it documented somewhere. At 3:04 PM, V3 said she was unable to find any documentation that R1 had refused the footrests. V3 said she could see how having the footrests in place could have reduced R1's risk of falling. V3 said residents have the right to fall, but we should be doing everything we can to keep them safe. On 10/9/25 at 1:33 PM, V11 (Certified Occupational Therapy Assistant - COTA) said the proper way to propel a resident in a wheelchair included ensuring the resident is properly positioned, unlocking the brakes, and pushing slowly with the footrests in place. V11 said the footrests keep the resident's legs safe from dangling or getting run over from the wheelchair. V11 said the footrests are important for the resident's safety. V11 said even if a resident can self-propel, staff should still use footrests when they propel the resident. On 10/9/25 at 2:11 PM, V13 (Therapy Director/ Physical Therapist) said the purpose of footrests while pushing a resident was for safety. V13 said you never know if they can hold up their legs, they could wear out. V13 said if a resident was properly positioned in a wheelchair with the leg rests on, then they should remain safely in the wheelchair. V13 said using the leg rests should alleviate the risk a bit of falling forward out of the chair. The surveyor requested a wheelchair transport policy, but none was received. The facility's Safe Lifting and Movement of Residents Policy dated 2017 showed, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to live and move residents. Policy Interpretation and Implementation: 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding safe lifting and moving of residents. 145917 Page 3 of 3