Health inspection·April 1, 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 observation, interview and record review the facility failed to ensure fall interventions were in place for residents with a history of falls for 2 of 3 residents (R2, R3) reviewed for safety and supervision in the sample of 3. The findings include: 1. R2's Fall Risk assessment dated [DATE] showed R2 had eight (8) falls in the facility from 2/2/24-3/27/24. The assessment showed the facility utilized chair and bed alarms as fall interventions for R2. R2's current care plan showed R2 remained at high risk for falls related to her unsteady gait, history of previous falls, and diagnosis of dementia with behaviors. The care plan listed alarms on chair and bed to alert staff of unplanned movement as one of R2's fall interventions since 3/1/23. On 3/28/24 at 9:50 AM, R2 was in bed. R2's upper body (head, torso, buttocks) were on the bed. R2's legs were off the bed, propped up on the seat of a wheelchair, that was positioned next to R2's bed. No mats were noted on the floor next to R2's bed. Folded floor mats were noted against the wall, by the foot of R2's bed. A pad alarm was placed partly under R2's buttocks and partly hanging off R2's bed. The cord attached to the pad was not connected to the alarm box. The cord laid on the floor, under R2's bed. The alarm box was turned off, hanging off the siderail of R2's bed. On 3/28/24 at 11:30 AM, R2 was in bed, with her entire body positioned in the bed. The pad alarm was in place, under R2 and turned on. V4 (Family of R2) was seated in a chair, next to R2's bed. V4 stated that when he arrived that morning, he too found R2 with her upper body in bed and her feet in a wheelchair next to the bed. He also found R2's pad alarm had been disconnected and turned off. V4 stated, That happens a lot. When I come in and the alarm isn't on. She needs the alarm. She has a weak back and is constantly moving around, trying to get comfortable. When she moves around, she falls out of bed. She just fell out of bed again last night. On 4/1/24 at 9:07 AM, V8 Licensed Practical Nurse stated R2 should have a pad alarm or clip alarm in place due to her risk of falls. V8 also stated R2 is to have mats lying on the floor next to her bed anytime R2 is in bed. 2. A Facility Census Form dated 4/1/24 showed R3 resided in a room, on the skilled care/intermediate care wing, from 12/20/23-3/29/24. Page 1 of 2 146066 146066 04/01/2024 Alpine Fireside Health Center 3650 North Alpine Road Rockford, IL 61114

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R3's progress notes dated 1/1/24-3/29/24 showed R3 had three (3) falls in the facility on 1/21/24 (2 falls) and 1/25/24. A note dated 1/21/24 at 7:41 PM showed R3 fell as he was trying to get out of his recliner. A note dated 1/25/24 showed clip and bed alarms had been placed on R3 as fall interventions. R3's current care plan showed R3 remained at risk for falls due to his history of previous falls, unsteady gait, and the amputation of toes to his right foot. The plan showed, Clip and bed alarm in place to alert staff of any unplanned movement. On 3/28/24 at 9:56 AM, R3 was seated in a recliner in his room. No pad alarm was noted under R3. No clip alarm was attached to R3. A clip alarm was noted hanging off the handle of a wheelchair in R3's room. The clip alarm was turned off. On 4/1/24 at 9:39 AM, V2 Director of Nursing stated floor mats and position alarms are used as fall interventions for residents in the facility. V2 stated, If a resident is at high risk for falls, we do use bed/chair alarms and floor mats next to their beds as fall interventions. We also try to keep them in view of our staff. CNAs (certified nursing assistants) should be checking many times during their shift to make sure alarms are in place and working. If a resident needs an alarm, it's documented on their care plan. The facility's Fall Policy (undated) showed, On admission and re-admission, a Fall Risk Assessment will be completed. Interventions will then be implemented for those residents assessed at risk for falls. These measures will be documented in the Plan of Care . The facility's Fall Prevention Program policy (undated) listed assisted devices/alarms and low bed/mat on the floor as fall interventions used in the facility. 146066 Page 2 of 2