Health inspection·October 30, 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 follow their fall focus program for one resident who was identified as moderate risk for falls, by not ensuring the resident's entire bathroom floor was dry prior to assisting him with care. This affected one of three residents (R1) reviewed for safety during care. This failure resulted in R1 sustaining a witnessed fall resulting in an impacted intertrochanteric fracture of the proximal right femur (right hip fracture).Findings include:R1 was admitted to the facility on [DATE] with a diagnosis of down syndrome, severe intellectual disabilities, mood disorder and osteoarthritis. R1's brief interview for mental status score dated 9/26/25 documents a score of 8/15 which indicates mildly impaired. R1's functional abilities dated 9/26/25 documents supervision or touching assistance for personal hygiene, shower transfer, putting on/taking off footwear, upper and lower body dressing. Under shower/ bathe self documents: R1 requires partial/moderate assistance.R1's fall assessment dated [DATE] documents moderate risk for falls. Under gait analysis documents: unable to independently come to standing position, exhibits loss of balance while standing, decrease muscle coordination and strays off straight path of walking.R1's incident report dated 10/13/25 documents: Resident was taking a shower had a slip and hurt his buttocks area. The fall was witnessed no injury to head. Resident reports pain to right leg. Under predisposing environmental factors wet floor is marked.On 10/28/25 at 2:06pm, V4 (CNA/Certified Nurses Assistant) said she was passing by R1's room and heard the water. V4 said she entered the room and observed R1 undressed in his bathroom with wet towels. R1 was soaking the towels in the sink with water and then going to shower and squeezing the water onto himself because the shower head was turned off and only had a small amount of water coming from the shower head. V4 said she tried to convince R1 to come out of the bathroom, but he was refusing. V4 said there was water all over the floor. V4 said the floor was still wet with puddles where R1 was standing but had dried the other half of the floor. V4 said, V5 (CNA) heard them and came into the room to assist. V4 said R1 started listening to V5 and V4 was able to dry off R1 and assisted him to get dressed with cueing. R1 had a shirt, pants, shoes on and was reaching to put on his sweater that V5 was holding. V5 and V4 were walking out of the bathroom to try to get R1 to come out to put his sweater on when R1 slipped and fell to his buttocks. On 10/29/25 at 12:21pm, V5 (CNA) said on day of incident he was in the hallway and heard R1. He went into R1's room to assist. R1 was already out of the shower and had pants and shoes on. The floor was wet because R1 had a cup that he was filling with water at the bathroom sink and bringing to the shower to bathe. R1 needed to get his shirt on and was assisted by staff V4 who was in the room as well. R1 was not being resistive with care at that time. V5 said he had R1's sweater and when R1 went to grab it he slipped and started to fall. V5 said he tried to stop him from falling but R1's weight took him down and the position he was in due to the toilet being in the way.R1's right femur x-ray report dated 10/13/25 documents: an impacted intertrochanteric fracture of the proximal right femur with Page 1 of 2 145946 145946 10/30/2025 Pearl of Hillside,the 4600 North Frontage Road Hillside, IL 60162

F 0689 Level of Harm - Actual harm Residents Affected - Few varus deformity.Facility Fall prevention and management policy revised 3/31/25 documents: The facility is committed to its duty of care to residents and patients in reducing risk, the number of consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. Universal fall precautions will be implemented to all residents admitted to the facility regardless of risk scores. Fall focus program will be implemented to ensure purposeful rounding addresses residents positioning, pain, personal needs. personal items within reach, safety hazards and peaceful environment upon admission and throughout resident stay.Facility fall focus program undated under protection/safety hazards documents: Staff will assess its physical environment, device, equipment, including furniture, appliances, beds, wheelchairs etc to ensure that it don't pose a safety risk or hazard. Rooms and hallways should always be clutter free. Floors and surfaces should be clean and dry. 145946 Page 2 of 2