Health 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 Page 1 of 3 145980 145980 12/13/2024 Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174

F 0689 Level of Harm - Actual harm Residents Affected - Few said R1 slid and rolled out of the bed when she turned her on her right side. V3 said she was new and felt rushed because she was unfamiliar with R1's care needs. V3 said she noticed R1 had a sticker on her bed indicating she was a 2-person total mechanical lift transfer but was unsure how much assistance she required with bed mobility. V3 said she was not trained on how to determine the level of assistance a resident requires with their ADLs (Activities of Daily Living) of bed mobility and positioning. On 12/12/2024 at 2 PM, V2 (Director of Nursing/DON) said she expects new CNAs to be trained on bed mobility during orientation. V2 said V3 (CNA) was educated on 12/7/2024 (after R1's fall incident) on the need to provide 2-person staff assistance when rendering care to resident on an air-loss mattress. V2 said V3 failed to have another staff member assist her while she was providing incontinence care to R1 on 12/7/2024. On 12/12/2024 at 2:15 PM, V11 (Physician) said R1 required staff assistance with her ADLs because she had chronic hemiparesis to her left side related to her stroke. V11 said she depends on therapy and nursing to assess residents to determine how much assistance they require with their ADLs. V11 said R1's fall on 12/7/2024 resulted in her sustaining fractures to her left leg. V11 said she expected facility staff to follow safety protocols when rendering care to ensure the safety of residents. R1's Mobility assessment dated [DATE], showed R1 had a poor ability to roll from side to side with the use of her left side. The assessment also showed R1 had a poor range of motion, muscle strength, mobility, and balance to her left upper and lower extremities. R1's Physical Therapy Discharge summary dated [DATE], showed R1 required substantial/maximal assistance from facility staff for bed mobility when rolling left to right side. R1's Fall assessment dated [DATE], showed R1 was at Moderate Risk for falls. R1's Fall Event dated 12/7/2024, said R1 fell out of bed when the CNA rolled her on her right side. R1's Progress Note dated 12/9/2024 said an IDT (Interdisciplinary Team) Review was done regarding R1's fall on 12/7/2024. The Progress Note showed Root Cause: inability to maintain balance during ADL care .Interventions .staff to complete cares in pairs. R1's Care Plan reviewed on 12/12/2024, showed a fall prevention intervention initiated on 12/7/2024 (post-fall) for Positioning: Staff will ensure that resident is centered in bed .and trunk and extremities are properly aligned and supported. R1's care plan also showed an intervention of Resident currently requires assistance with ADLs: Bed Mobility: Extensive initiated on 2/2/2024. R1's comprehensive care plan does not indicate the number of staff members R1 requires for her extensive bed mobility care needs. The facility's policy titled Fall Prevention and Management dated 4/8/2024, said The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained .Interventions will depend on identified and assessed risk factors, including root cause/s every after each fall or when a pattern has been identified. Some of these interventions may include but not limited to .Restorative Program .Bed Mobility .Development of the fall interventions plan is based on results of the Falls Assessment as well as investigation of all circumstances and related 145980 Page 2 of 3 145980 12/13/2024 Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174

F 0689 resident outcomes . Level of Harm - Actual harm The facility's policy titled Supporting Activities of Daily Living (ADL) dated 11/7/2024, said Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .including appropriate support and assistance with .b. Mobility (turning, re-positioning .) .A resident's ability to perform ADLs will be measured using clinical tools .The resident's response to interventions will be monitored, evaluated, and revised as appropriate . Residents Affected - Few 145980 Page 3 of 3