Health inspection·January 17, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure a resident was safely transferred with a mechanical lift for 1 of 4 residents (R1) reviewed for falls in the sample of 4. Residents Affected - Few The findings include: R1's Physician Order Sheet, printed on 1/17/25, shows R1 has diagnoses that include dementia, weakness, meniers disease, and hearing loss. R1's fall risk assessment, dated 1/8/25, shows R1 is high risk or falls. R1's careplan, dated 4/6/24, shows R1 is a risk for falls due to vision, hearing, weakness, gait balance problems with intervention to include transfer status, mechanical lift with 2 staff. On 1/17/25 at 10AM, R1 was lying in bed. Through communication board, he was able to say he was ok and was not in pain. V3 (License Practical Nurse-LPN) checked R1's head. A diffuse bruise, reddish black in color, was noted at the back of his head. R4 (R1's wife and roommate with a BIMS of 14-no cognitive impairment) said she was not in the room on 1/8/25 when the incident happened. She went to the dining room to get coffee. When she came back, R1 was noted lying on the floor. I came in, knelt down by him and put my hand beneath his head, I felt a big goose egg at the back of his head. He (R1) was alert but was just staring straight up, he looked shocked. He was sent to the hospital and came back. He has bruising at the back of his head. R4 said she was told R1 was being lifted from his wheelchair to bed. R1 fell backwards with his wheelchair with him, hitting his head on the floor. R4 said there should always be a staff behind R1 during transfers. On 1/17/25 at 10:15 AM, V7 (Certified Nursing Assistant-CNA) said she was one of the CNAs on 1/8/25 who transferred R1 using the mechanical lift. V7 said she was in front of R1 doing the controls, while V6 (CNA) was on R1's side. V7 said when R1 was being lifted via the mechanical lift, R1's wheelchair was also being lifted with him. V7 said they put R1 back down and checked what was going on; if any of the slings were being caught. Then they tried again. As R1 was being lifted via the mechanical lift the 2nd time, R1's wheelchair tipped backwards with R1 in the wheelchair, hitting his head on the floor. The mechanical lift sling was not securely attached to the metal hook. V7 said it happened so fast, we tried to grab him but he was already on the floor. V7 also said they were so focused on why the wheelchair was going up with R1, and were not able to ensure all the hooks/slings were secured. Page 1 of 2 146077 146077 01/17/2025 Serenity Estates at Morris 1223 Edgewater Morris, IL 60450

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/17/25 at 10:51 AM, V6 (CNA) said she was with V7 (CNA) on 1/8/25 transferring R1 from wheelchair to bed. As R1 was being raised via mechanical lift, the wheelchair was going up with R1. R1 was lowered down. As R1 was being lifted back up again, the mechanical sling on the right side came off. R1 tilted backwards with his wheelchair to the floor. V6 stated, (R1's) a heavy-set guy, we tried to grab him, but he still fell backwards. (R1) hit his head on the floor. V6 said she was on R1's left side, and not behind the wheelchair, so she was not able to stop the wheelchair tipping backwards. On 1/17/25, at 9:40 AM, V3 (License Practical Nurse- LPN) said she was the Nurse working on 1/8/25 when the incident happened. V7 and V6 (CNA's) were transferring R1 from his wheelchair to bed via mechanical lift. As R1 was being raised up, the wheelchair tilted backwards with R1 in it. The part of the loop (sling) came off. R1 fell backwards with his wheelchair hitting his head on the floor. V3 said fall assessments show no injury except redness at the back of his head. R1 was sent out via 911 and came back the same day. All tests were negative. R1's hospital records, dated 1/8/25, show R1 was diagnosed with scalp hematoma (bruise) and was discharged back to the facility same day (1/8/25) On 1/17/25 at 12:30 PM, V8 (Physical Therapist) said, When transferring a resident via mechanical lift, the resident should be positioned well under the pad. Make sure all straps (slings) were not getting caught on the wheelchair, all 4 slings securely placed in all the hooks and checking the sides and back to ensure resident is safe during the transfer. On 1/17/25 at 9:18 AM, V1 (Administrator) said all staff have been re-trained (including V6 and V7) regarding safe transfers using the mechanical lift. The facility policy entitled Safe Resident Handling/Transfers (undated) states, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and and provide and promote a safe, secure and comfortable experience for the resident while keeping the employee safe in accordance with current standards and guidance. 146077 Page 2 of 2