Health inspection·August 13, 2025

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 that recommended fall preventive measures were put in place at all times for residents who were identified as high risk for falls. This applied to 2 of 3 residents (R2, R4) reviewed for falls in the sample of 5. The findings include: Findings Include: 1. R2's face sheet documents R2 is 82 years-old who has multiple medical diagnoses including repeated falls, unsteadiness on feet, lack of coordination, and Alzheimer's disease. R2's Minimum Data Set, dated [DATE], shows R2 is cognitively impaired. Facility's fall incident log, dated May 8 to August 12, 2025, shows R2 had multiple fall incidents on May 31, June 13, June 16, June 19, July 3, and July 13, 2025. R2's fall care plan with initiated date of May 30, 2025, shows: R2 is at risk for falls in relation to poor safety awareness, history of falls, and dementia. This same care plan shows multiple interventions which include wheelchair cushions with non-skid mat (Dycem) to chair. On August 7, 2025, from 2:50 PM to 3:28 PM, R2 was observed in the unit D dining room. R2 was sitting in her wheelchair, she was restless and was attempting to stand up. There was no sign of non-skid mat on the wheelchair seat. At 3:28 PM, V13 (Certified Nursing Assistant/CNA) assisted R2 to stand up with use of gait belt, however, there was no non-skid mat on the wheelchair seat. On August 11, 2025, R2 was observed multiple times. At 9:35 AM, R2 was sitting in her wheelchair in the dining room, and at 12:00 PM, she was eating in the dining room. Both times R2 does not have non-skid mat on her seat. On August 11, at 1:44 PM, V8 and V9 (Both CNAs) assisted R2 to the toilet with the assistance of V6 (Nurse). V8 and V9 assisted R2 to transfer from wheelchair to toilet seat. There was no non-skid mat in the wheelchair. 2. R4's face sheet shows R4 is 78 years-old who has multiple medical diagnoses including specified disorders of muscle, lack of coordination, repeated falls, and vascular dementia. Facility's fall incident log, dated May 8 to August 12, 2025, shows R4 had multiple fall incidents on May 27, June 8, June 13, June 14, August 6, and August 10. R4's care plan with revision date of August 6, 2025, shows R4 is at risk for falls in relation to poor safety awareness, use of an anti-depressant, use of a diuretic, dementia diagnosis, vertigo, and history of falls. This same care plan shows multiple inventions which include non-skid mat to wheelchair. On August 7, 2025, at 3:06 PM to 3:24PM, R4 was observed sitting in her wheelchair in the day room with other residents. There was no sign of non-skid mat on her seat. At 3:24 PM, V13 assisted R4 to stand up with the use of gait belt, however, there was no non-skid mat on her wheelchair. On August 11, 2025, R4 was observed multiple times. At 9:40 AM, R4 was in the hallway sitting in her wheelchair. At 1:20 PM, R4 was in the hallway socializing with R5. Both times R4 did not have the non-skid mat on her wheelchair seat. On August 11, 2025, at 1:28 PM, V8 and V9 (Both CNAs) assisted R4 to the bathroom. There was no non-skid mat on her wheelchair seat. V8 stated she had never seen R4's wheelchair seat with a non-skid mat. On August 12, 2025, at 10:51 AM, V15 (Nurse) stated, To prevent fall incidents one needs to find the root cause of the fall such as catching UTI (urinary tract infection) Page 1 of 2 146077 146077 08/13/2025 Serenity Estates at Morris 1223 Edgewater Morris, IL 60450

F 0689 Level of Harm - Minimal harm or potential for actual harm early, keeping the residents busy with activities, and regular toileting, understanding reason for falls and following recommended fall interventions. On August 12, 2025, at 11:37 AM, V2 (Director of Nursing/DON) stated she places multiple interventions for fall preventions such as hourly monitoring and non-skid chair mat on the wheelchair for people who have poor safety awareness and high-risk for fall. V2 also said she expects the staff to follow these interventions. Residents Affected - Few 146077 Page 2 of 2