Health inspection·January 3, 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 Based on observation, interview, and record review the facility failed to safely transfer a resident for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a left leg laceration requiring 29 sutures. The findings include: The facility's Reported Incident Final dated 12/29/23 shows on 12/27/23, R1 sustained a skin tear to left lower extremity. Per staff interviews on file, it was noted resident was being assisted by 2 Certified Nursing Assistants (CNA) from wheelchair to bed using a mechanical lift. During the transfer resident was noted to bump leg on wheelchair. On 1/3/24 at 9:15 AM, R1 was sitting up in a reclining wheelchair in her room. R1 had padded protection sleeves on both arms and lower legs. V4 CNA rolled the padded sleeve down on R1's left lower leg. R1 had a gauze bandage covering her left lower leg. R1 stated I had 29 stitches. It hurts still. I can tell there is something there. V4 said she and V5 CNA were transferring R1 from her bed to the wheelchair and they bumped R1's leg on the wheelchair. V4 said R1 had the sleeves on her legs at the time. V4 said they were in the process of lowering R1 into the wheelchair when R1 said ouch! V5 entered the room, joined the conversation, and said when R1 said ouch, they finished lowering her to the wheelchair and then rolled down the protective sleeve. V5 said there was a large piece of skin hanging with fresh bright red blood dripping. V5 said the skin tear was very large and was more long than wide. V4 and V5 said they got the nurse right away. R1 said she remember saying ouch when being transferred but didn't remember what her leg bumped. On 1/3/24 at 9:34 AM, V3 Registered Nurse lowered R1's protective sleeve on her left leg. V3 removed the gauze dressing. R1's left lower shin contained a large uneven laceration with visible sutures. R1's wound had sutures visible along the edges where R1's skin flap was secured back in place. R1's wound was red with some open areas that appeared moist. R1 complained of soreness during the dressing removal and change. V3 said R1 had picked out some of the sutures herself and was scheduled to have the sutures removed after 10 days. V3 said R1's laceration happened during a transfer with the mechanical lift. R1's Hospital Emergency Department Physician Note dated 12/27/23 shows Patient has a laceration to her left distal shin. Patient is bed bound, injured while on mechanical lift at facility. Laceration is 6 centimeters in length. Shape: irregular, flap. Skin closure: 29 sutures, simple technique, interrupted technique. The same paperwork shows R1 was prescribed tramadol 50 mg twice daily for pain. The facility's witness statement from V4 dated 12/27/23 shows shortly after 3 PM, this CNA and Page 1 of 2 146084 146084 01/03/2024 LA Bella of Morrison 500 North Jackson Street Morrison, IL 61270

F 0689 Level of Harm - Actual harm Residents Affected - Few another CNA (V5) used the mechanical lift to transfer R1 into her reclining wheelchair. During the transfer residents left leg hit side of chair. R1 said ouch my leg. After we lowered her into chair, V5 pulled down leg sleeve then noticed skin. Nurse was then notified. The facility's witness statement from V5 dated 12/27/23 shows shortly after 3 PM went to check and change resident, when done transferred her into the reclining wheelchair and her leg hit the side of the wheelchair. The resident said ouch. We proceeded to lower her into the chair. When resident was safely in her chair, I pulled down the leg sleeve and noticed a skin tear and notified the nurse. On 1/3/24 at 10:24 AM, V1 Administrator said the investigation revealed that R1's injury happened during the transfer when her leg hit the side of the wheelchair. The facility's Limited Lift Resident Handling Policy and Procedures shows purpose: to ensure that employees use safe resident handling and movement techniques for tasks that are designated as high-risk for safe resident handling and movement injuries. 146084 Page 2 of 2