Inspection·December 13, 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 interview and record review the facility failed to safely assist and position a resident (R1) in bed when rendering care. This failure resulted in the resident falling out of bed and sustaining left tibial and ankle fractures. This applies to 1 out of 3 (R1) residents reviewed for accidents. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, post-orthopedic surgery to both ankle tendons, history of other disease of the nervous system, and history of malignant neoplasm of the brain. R1's Hospital Records dated 12/8/2024, said [R1] fell approx. (approximately) 4 ft from bed while being changed by CNA. She states she rolled off on the right side of the bed landed on left side. The hospital records continued to say R1 sustained left tibial and ankle fractures. On 12/12/2024 at 12:50 PM, V4 (Licensed Practical Nurse/LPN) said on 12/7/2024 she assessed R1 after her fall incident. V4 said R1 was complaining of pain and had to be transferred to the hospital. V4 said R1 returned to the facility with a long leg cast to her left lower leg because she had sustained multiple fractures. V4 said R1 had always needed a 2-person staff assistance with bed mobility because she had chronic left-side weakness in both her upper and lower extremities. On 12/12/2024 at 1 PM, V9 (Restorative Nurse) said she assessed R1's mobility function on 9/14/2024 and determined R1 required the use of bilateral enablers (quarter-size side rails) and 2-person staff assistance when receiving care in bed on her air-loss mattress. V9 said R1's ADL care plan showed she required extensive assistance with bed mobility. V9 was unable to locate in R1's comprehensive care plan her intervention indicating that R1 required a 2-person staff assistance with bed mobility and positioning when in bed. On 12/12/2024 at 1:15 PM, V10 (Therapy Rehab Director) said he was familiar with R1 because she was discharged from therapy services on 10/14/2024. V10 said R1 required substantial to maximal assistance of 2-staff members with her bed mobility. V10 said he had trained the facility's CNAs on how to safely position residents in bed when rendering care. V10 said R1 should have been assisted by 2-staff members, one on each side of the bed to ensure her safety when being turned in the bed. On 12/12/2024 at 1:40 PM, V3 (Certified Nurse Assistant/CNA) was interviewed regarding R1's fall incident on 12/7/2024. V3 said at approximately 4 PM she assisted R1 in bed with incontinence care. V3 (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: 145980 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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)