Health inspection·December 13, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transfer a resident safely for 1 (R1) of 3 residents reviewed for accidents in the sample of 6. This past non-compliance occurred between 12/01/2024 to 12/13/2024. The findings include: R1's admission Record documents R1 was admitted to the facility on [DATE] and includes diagnoses of cerebral aneurysm, non-ruptured, contracture of muscle, multiple sites, adult failure to thrive, altered mental status, delusional disorder, generalized anxiety disorder, and Paroxysmal Atrial Fibrillation. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 01, indicating R1 has severe cognitive impairment. The same MDS documents that R1 has impairment on both upper and lower extremities, is dependent for showers, bed to chair transfers, and getting in and out of shower. R1's Care Plan documents that R1 has an ADL (Activities of Daily Living) self-care performance deficit. Documented interventions include that R1 requires extensive assist with bathing/dressing/hygiene and R1 requires two assist with full body mechanical lift for all transfers. R1's [NAME] documents for Toilet Use: R1 requires two assist with full body mechanical lift for all transfers and R1 requires two assist with full body lift for all transfers or two assists with transfers. R1's Physician's Orders dated as of 11/1/2024 document an order for Eliquis tablet 2.5mg (milligrams) two times a day for AFib (Atrial Fibrillation). R1's Progress Note dated 12/2/24 at 12:51 PM by V12 (Licensed Practical Nurse) documents (R1) noted to have a large bruise to right forearm. (R1) reported that staff transferred her to shower without using hoyer (mechanical) lift yesterday afternoon. MD (physician) and POA (Power of Attorney) notified. R1's Nurse's Progress Note dated 12/2/24 at 3:21pm by V1 documents I spoke with (R1) today regarding a bruise that occurred the night before during a transfer prior to her shower. (R1) stated that the aides in no way intentionally set out to harm her in any way. She thanked me for talking with her Page 1 of 3 146019 146019 12/13/2024 Wabash Senior Living & Rehab 216 College Boulevard Carmi, IL 62821

F 0689 and had no other concerns at this time. Level of Harm - Minimal harm or potential for actual harm On 12/10/24 at 2:00pm, V2 (Assistant Administrator) said there was an incident on 12/1/24 involving R1 that occurred on 12/1/24. V2 said that there were 2 Certified Nurse's Aides (CNA), that do not usually work that hall, that gave R1 a shower. V2 said that instead of using the mechanical lift, they lifted R1 under her arms. V2 said that both staff told her that R1 never screamed or yelled or even told them they needed to use the lift. V2 said that the incident was brought to her attention on 12/2/24 (Monday) that R1 had a large bruise on her right forearm from not being transferred with the mechanical lift. V2 said that V15 (Certified Nurse's Aide/CNA) said that there were no issues with the mechanical lifts, they just didn't use it and lifted her without it. V2 said that they should have used the mechanical lift, but didn't. V2 also said that R1 is on Eliquis which is a blood thinner and does bruise easily. Residents Affected - Few On 12/10/24 at 11:30am, R1 was sitting in her recliner in her room. R1 said she did not want to talk about it and she had told the story a million times and was not going to say it again. R1 would not let this surveyor look at her arm. R1 was alert and answered questions appropriately at this time. On 12/12/24 at 11:25 AM, R1 was asked about the incident on 12/1/24 and R1 said they didn't use the lift and those girls were never going to shower her again. R1 said they are not allowed in her room again. R1 said she did not tell them to stop or to use the lift when they transferred her. R1 said that she is ok and that that will not happen again. R1 said they made this big bruise on her arm. R1 was asked to see the bruise and R1 would not let this surveyor look at the bruise. R1 was observed to have contractures in both hands and unable to use them. The lower part of the bruising towards her wrist was visible and it was reddish pink in color. R1 was alert and answered questions appropriately at this time. On 12/12/24 at 3:15 PM, V15 (CNA) said she worked on 12/1/24 and said she was told that R1 needed a shower and no one told her that she needed a mechanical lift. V15 said she was not aware of looking at the [NAME] and has been employed at the facility for maybe 9-10 weeks. V15 said that they transferred R1 under her arms and held the seat of her pants. V15 said that facing R1 she put her arm under R1's arms in the arm pit area and R1's arm pit area was in the bend of her arm. V15 said she also had ahold of the seat of R1's pants. V15 said that R1 did not scream or yell and all that R1 said they were never giving her a shower again. V15 said they used the shower in the 800 hall that was closed since the showers on the 500 hall were being used. V15 said that R1 never told them to stop and they should use the lift or they would have used it. V15 said to her knowledge, the lifts were not broken. V15 said there was bruising on R1's right arm before they showered her. V15 said after R1's shower, they lifted her back in bed. V15 said they did not use the lift putting her in bed. V15 also said she did not use a gait belt. On 12/10/24 at 3:24pm, V16 (CNA) said she was not aware that R1 required a mechanical lift for transfers. V16 said she was being trained and had only worked a couple of days. V16 said that on 12/1/24 she transferred R1 with V15. V16 said she was on the opposite side of V15 and placed her arm under R1's arm with R1's weight resting in the bend of her arm and used her other hand to hold the seat of R1's pants. V16 also said she did not use a gait belt. V16 said R1 never told them they needed to use the lift. V16 said they took R1 to the 800 hall to shower since the shower on the 500 hall was being used. V1 6 said that no one could have heard R1 screaming and yelling since she did not yell or scream at all. V16 said that R1 kept saying you will never give me a shower again and that was it. V16 said they showered her without any issues and then put her back in bed again not using the lift. 146019 Page 2 of 3 146019 12/13/2024 Wabash Senior Living & Rehab 216 College Boulevard Carmi, IL 62821

F 0689 Level of Harm - Minimal harm or potential for actual harm On 12/11/24 at 10:00am, V12 (Licensed Practical Nurse/LPN) said she came in on Monday (12/2/24) and saw bruising on R1's right arm. V12 said that R1 told her that the CNA's couldn't get the lift to work and lifted her under her arms and that is where the bruise came from yesterday (12/1/24) V12 said R1 also told her that they were transferring her to a chair. V12 said she took a picture of the bruise and reported it to administration on 12/2/24 and also called the physician and R1's POA (Power of Attorney). Residents Affected - Few On 12/11/24 at 10:50am, V14 (Registered Nurse/RN/Infection Preventionist/wound nurse) said that she is aware of the incident. V14 said she was not aware of any bruising present on R1's right arm prior to the incident on 12/1/24. The facility policy titles Safe Lifting and Movement of Residents (revised July 2021) documents Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. A resident that requires a mechanical lift may also be a two person assist with the use of proper equipment i.e (in example) gait/transfer belts. 146019 Page 3 of 3