Health inspection·October 26, 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 provide safe transfer assistance. This applies to 1 resident (R1) of three reviewed for safe transfers. This failure resulted in R1 incurring a acute nondisplaced bimalleolar fracture and a nondisplaced oblique fracture of the distal fibula. Findings include: 1. R1's Medical diagnosis from the electronic record documents R1 as a [AGE] year old, with diagnoses to include Aphasia, Hemiplegia and Hemiparesis following a Cerebral Infarction. The Final Report to Illinois Department of Public Health, dated 10/17/2/2024, documents, On 10/11/2024, The resident was lowered to the ground after becoming weak during a transfer from her electric wheelchair to her bed via pivot transfer. A (mechanical lift) was used to lift the resident from the floor to the bed after a head to toe assessment revealed no obvious injury and subsequent assessments had not indicated any observable abnormalities to the right lower leg/ankle area. The resident later expressed pain to her right lower extremity during the early morning hours of 10/12/2024 and was sent to the ER (Emergency Room) for evaluation and sent back later that morning with no fractures or dislocation noted and norco for pain management as needed. The resident continued to have pain to the right leg with repositioning in bed and 10/14/2024 Dr ordered X-rays to the right hip/right femur/and right knee with no fracture of dislocation indicated. Dr. rounded on 10/15/2024 to evaluate the resident and ordered another set of X-rays to the right tibia/fibula, right ankle and right foot with the results sent to the facility on [DATE] with an acute non-displaced bimalleolar fracture and a non-displaced oblique fracture of the distal fibula. Dr. was notified and gave orders to send the resident back to the hospital for evaluation which confirmed the bimmalleolus fractures which appear to be minimally displaced and a soft cast was applied to the right lower extremity. A chronic fracture deformity of the right humeral neck and deformity of the right distal humerus which may require an elbow series if acute symptoms are present. A right arm sling was placed and resident was transferred back to the facility. Resident currently with Tylenol ordered for pain per family request. The Radiology Results Report for R1, dated 10/15/2024, documents under Findings: Right Tibia and Fibula~ An acute nondisplaced bimalleolar fracture is noted. The Radiology Report for R1, dated 10/16/2024, documents under impression Right Ankle~Displaced fractures through the lateral malleous and medial malleous. The care plan for R1 documents, The resident is risk for falls r/t (related to) Deconditioning, Gait/balance problems. Resident will have 2 cna assist to bed from scooter. Will use sit to stand or (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 2 Event ID: 146077 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 146077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Serenity Estates at Morris 1223 Edgewater Morris, IL 60450 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)