Health inspection·December 24, 2024

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 ensure a resident was properly restrained while being transported in the facility van for 2 (R1 and R4) of 4 residents reviewed for accidents in a sample of 4. This failure resulted in R1 sustaining a laceration to her head requiring 14 staples and 8 sutures, a fracture to the second digit of the right foot, left nasal bone fracture with deviation of the septum, and bruising to the lower abdomen and upper thighs. Findings include: 1. R1's admission Record documented an admission date of 11/30/20 with diagnoses that included Parkinson's disease, difficulty in walking, unsteadiness on feet. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. On 12/19/24 at 10:25 AM, R1 was sitting in a wheelchair and had bruising noted below both eyes and a pink scar on her forehead disappearing into her hair line. R1 said she was involved in an accident in the facility transport van. R1 said she was buckled in her wheelchair with a belt on her lap. R1 said when the accident occurred R1 was thrown from her wheelchair and landed in the floor of the transportation van. On 12/19/24 at 2:49 PM, R1 said there was no seatbelt over her shoulder when the accident occurred. R1 said she was only restrained by the lap belt. R1 said when she had been thrown from her wheelchair her foot had gotten tangled in the lap belt causing pain. On 12/19/24 at 11:13 AM, V3 (Certified Nursing Assistant/CNA) said that on 11/27/24, she had transported R1 to the hospital for an appointment and was on the way to pick up another resident with R1 in the transportation van. V3 said while she was driving, she hydroplaned and thought someone had rearended the transportation van and then hit another vehicle that was stopped in the road. V3 said during the accident R1 had fallen out of her wheelchair into the floor of the transportation van. V3 said she did not know how R1 had fallen out of her wheelchair because R1 was buckled in. V3 said the seatbelts in the new transportation van are hooked to the rear brackets in the floor that hold the rear wheelchair wheels. V3 then demonstrated while sitting in a chair how the seatbelt is passed under the armrests of a wheelchair and buckle around the lower abdomen. V3 said the new transportation van did not have any seatbelt that went over the resident's shoulder. V3 said residents have the ability to unbuckle the seat belt but the transportation van has a sensor that tells you if the resident's seatbelt is unbuckled. V3 said the sensor was not on alerting her of R1's seatbelt being unbuckled. V3 said R1 had never unbuckled the seatbelt. V3 said some residents will unbuckle themselves when (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145918 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)