Health inspection·March 18, 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 interview and record review, the facility failed to safely reposition a resident in bed for one of seven residents (R1) reviewed for safety supervision in the sample of seven. This failure contributed to R1 experiencing multiple fractures which required a hospitalization. This past non compliance occurred from February 7, 2025 to March 8, 2025. The findings include: 1. R1's Face Sheet dated March 17, 2025 shows she was admitted to the facility with diagnoses including fibromyalgia, morbid obesity, spinal stenosis, cervical spine fusion, major depressive disorder, repeated falls, and pain. R1's Care Plan dated August 16, 2019 shows R1 is requiring almost total care by staff. Assist of two people for all transfers. R1's MDS (Minimum Data Set) dated February 3, 2025 shows R1 is cognitively intact. R1 requires substantial/maximal assistance for rolling left and right in bed. R1 has impairments on both sides of upper and lower extremities. R1's Fall Risk assessment dated [DATE] shows she has a significant risk of falling. R1's Departmental Notes dated February 8, 2025 at 1:51 AM shows, Patient was receiving care by CNA (Certified Nursing Assistant), when she rolled to her right side. She stated she could not hold on and fell onto the floor. When this nurse came to assess patient she was observed on the floor laying partially face down with half her body on the bottom of the bedside table. Patient has an injury noted to the left lower leg, bruise to the right lower leg and pain to the left upper shoulder. Range of motion severely limited to left arm related to fall. Patient was sent to emergency room by ambulance via stretcher at 12:30 AM. R1's Hospital Records dated February 8, 2025 shows, Fall at nursing home. Humerus shaft fracture, laceration of leg, pubic ramus fracture. On March 17, 2025 at 9:18 AM, R1 said the CNA was in a hurry the evening of her accident. It was an unnecessary accident. R1 gave the first name of the CNA (V6). R1 said that she was on a low air loss mattress. The girl was throwing me around. I fell on the floor hard. I fractured my left arm in two places and I injured my pelvis. I got stitches in my left leg. I fell to my right side off of the Page 1 of 3 145935 145935 03/18/2025 The Citadel at Saint Joseph Village 659 East Jefferson Street Freeport, IL 61032

F 0689 Level of Harm - Actual harm Residents Affected - Few bed. Now I am afraid to be positioned on that side. I went down hard. She was on my left side and she pulled the pad up to help me turn and I rolled off of the bed. They usually use two people to turn me in bed. She was by herself. On March 17, 2025 at 12:36 PM, V5 CNA said she has taken care of R1 in the past. V5 said she has been taking care of R1 for a long time. V5 said she has never seen R1 require one person for assistance. V5 said R1 has always been a maximum assist with two people, even before her fall out of bed. On March 17, 2025 at 2:17 PM, V6 CNA said she was taking care of R1 when R1 fell. V6 said she woke R1 up and asked if she needed to be changed. V6 said she grabbed the pad underneath R1 to help her turn onto her right side. V6 said R1 rolled off of the bed onto the floor. V6 said R1 hit her left side on the bedside table. V6 said she tried to pull R1 back over, but it was too late. V6 said R1 was bleeding from her left leg and complained that her left shoulder was bothering her. V6 said she has taken care of R1 by herself many times before. On March 17, 2025 at 1:33 PM, V3 ADON (Assistant Director of Nursing) said R1 was being taken care of by the CNA when the CNA had R1 roll to the opposite side that the CNA was on and R1 went to the floor. V3 said R1 was transferred to the hospital and had fractures. V3 said prior to R1's fall, R1 was on a low air loss mattress, which means it should be two CNAs taking care of the resident on each side of the bed. V3 said that's facility policy. V3 said two assist due to residents risk of falls. V3 said she interviewed V6 in regards to R1's incident. V3 said V6 was not aware that if a resident is on a low air loss mattress, then two staff should be repositioning the residents. V3 said R1's fall could have been prevented had there been two staff in R1's room. V3 said that R1 was hospitalized for more than one day. R1's Safety Event Manager dated February 8, 2025 shows, Contributory Factors and Issues Leading to this Event: One CNA providing care on an air mattress. Prior to the survey date of March 18, 2025, the facility had taken the following actions to correct the noncompliance: 1. R1 was assessed by nursing staff on February 8, 2025 and sent to the emergency department. R1's Care Plan has been reviewed and updated. 2. Other resident residing in the facility as of February 8, 2025 who have air mattresses have the potential to be affected. These residents will be monitored for proper bed mobility by quality director on or before March 8, 2025. 3. Will ensure all staff is educated on the policy and procedure related to providing care for residents who utilize and air mattress. 4. Nursing staff will be re-educated on providing care for residents who utilize an air mattress by ADON on or before March 8, 2025 or prior to working their next scheduled shift. 5. The policy and procedure bed mobility has been reviewed and is deemed appropriate. 6. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. 145935 Page 2 of 3 145935 03/18/2025 The Citadel at Saint Joseph Village 659 East Jefferson Street Freeport, IL 61032

F 0689 7. Audits will be submitted and reviewed by the QAPI committee for management of ongoing compliance and will continue until otherwise determined by QAPI. Level of Harm - Actual harm 8. The administrator is responsible for ensuring ongoing compliance. Residents Affected - Few residents on an air mattress. 145935 Page 3 of 3