Health inspection·April 3, 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 provide adequate supervision/assistance when ambulating a resident to prevent a fall for one of four residents (R2) reviewed for accidents in the sample list of four residents. This failure resulted in R2 falling and suffering a fractured humerus when staff stepped away from R2 to untangle oxygen tubing. Findings include: The Care Plan dated 4/1/25 documents R2 was admitted to the facility on [DATE]. The Care Plan dated 4/1/25 documents R2 was admitted with the following diagnosis: systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, chronic gout, morbid (severe) obesity due to excess calories, polyneuropathy, dependence on renal dialysis, end stage renal disease, cellulitis of left lower limb, cellulitis of right lower limb, type 2 diabetes mellitus with diabetic nephropathy, hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease, dyspnea, muscle wasting and atrophy, multiple sites, unsteadiness on feet, and other lack of coordination. The Nurses Progress Notes dated 2/28/2025 at 2:40 PM document R2 was walking with therapy with the walker as the therapist trailed behind with the wheelchair. The therapist was attempting to adjust the oxygen tubing when the resident had some weakness and lost balance. The Note documents R2 complained of right shoulder pain and was unable to perform range of motion. R2 was subsequently sent to the local emergency room. On 4/1/25 at 2:07 PM V3, Physical Therapy Aide, stated that V3 was ambulating R2 in the hallway. V3 stated R2 was using a walker for ambulation, when R2's oxygen tubing became tangled around the wheelchair that was being pulled behind R2 during ambulation. V3 stated V3 bent over to untangle the tubing and R2 fell forward landing on the floor. On 4/1/25 at 2:07 PM V3, Physical therapy aide, demonstrated being behind the wheelchair bent over to untangle the oxygen tubing and unable to reach R2 due to the gap between V3 and R2. The Physical Therapy Progress Note dated 2/28/2025 at 4:20 PM documents R2 as requiring CGA (Contact Guard Assist) for ambulation with recovery breaks in between each set. The Note documents R2 notes increase in fatigue and SOB (Shortness ff Breath). R2 fell this session, while standing, R2's oxygen tube was caught on the wheelchair. While dislodging the tube R2 fell forward and has an abrasion on her right knee, elbow and cheek bone notified nursing of the accident. Page 1 of 2 145965 145965 04/03/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0689 Level of Harm - Actual harm Residents Affected - Few On 4/2/25 the NIH (National Institute of Health) Web Site defines Contact Guard Assist as the caregiver places one or two hands on the patient's body to help with balance but provides no other assistance to perform the functional mobility task. https://www.ncbi.nlm.nih.gov. Hospital Records dated 2/28/25 at 4:18 PM document R2 arrived at the hospital with a Chief Complaint of fall while doing physical therapy and that R2 reports right shoulder pain and states she hit her face as well. Hospital Records dated 2/28/25 at 6:17 PM document R2 was diagnosed with a closed comminuted fracture of the right humerus, facial contusion, multiple abrasions and right elbow pain. On 3/31/25 at 11:24 AM V5, R2's Family, confirmed that R2 was admitted to the hospital for a fractured right humerus and needed surgical repair. On 4/1/25 at 10:00 AM V1 confirmed that V3 was ambulating R2 in the hallway by himself with a walker while trailing R2 with a wheelchair that was carrying R2's oxygen on the back of the wheelchair. On 4/1/25 at 10:40 AM V9, Director of Rehabilitation, confirmed V3 was ambulating R2 in the hallway by himself with a walker while trailing R2 with a wheelchair that was carrying R2's oxygen tank on the back of the wheelchair. V9 confirmed V3 was behind the wheelchair and not in reach of R2 or the gait belt around R2. V9 confirmed two staff members will be used to ambulate residents with multiple pieces of equipment. 145965 Page 2 of 2