Health inspection·January 6, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on record review and interview the facility failed to update fall care plans with newly developed fall interventions for two of three residents (R1 and R3) reviewed for falls in the sample of three. Residents Affected - Few Findings include: The facility's Care Plan Policy dated 6-1-22 documents, It is the policy of this facility to develop and implement a base line care plan, a comprehensive person-centered care plan, and conduct care plan meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's mental, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The facility's Accident/Incident Preventions undated policy documents, When a resident has been identified as a high risk for accidents/incident, interventions will be put into place per the individual resident assessment and care plan. 1. R1's Fall with Injury Investigation dated 12-6-23 documents, (V8/CNA/Certified Nursing Assistant) was pushing (R1) down the hall after breakfast. (R1) leaned forward and fell. (R1) wheelchair did not have footrest. Inservice staff: Wheelchair foot pedals store in the bag for easy access to staff. Foot pedals in place when transporting residents. R1's Fall Care Plan dated 12-6-23 through 1-5-24 does not include the newly developed fall intervention dated 12-6-23 to ensure foot pedals are in place when transporting R1 and to ensure R1's foot pedals are stored in a bag when not in use for easy access of staff. 2. R3's Event Report dated 12-27-23 documents, (R3) was found on the floor in sitting position with wheelchair slightly behind (R3) unlocked. Interventions: Educated CNAs on being sure if (R3's) wheelchair is by her bedside it needs to be locked. R3's Fall Care Plan dated 12-27-23 through 1-5-24 does not include the newly developed fall intervention dated 12-27-23 to ensure R3's wheelchair is locked whenever placed by R3's bedside. On 1-5-24 at 11:05 AM V2 (Director of Nursing) stated, (R1's) fall interventions to ensure (R1's) foot pedals were stored in a bag when not in use, and to ensure (R1's) foot pedals were in place when being transported is not on (R1's) fall care plan. (R3's) fall interventions to ensure (R3's) wheelchair is in the locked position when placed beside (R3's) bed is not on (R3's) fall care plan. Page 1 of 5 146108 146108 01/06/2024 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0657 Level of Harm - Minimal harm or potential for actual harm On 1-5-24 at 11:15 AM V6 (Care Plan Coordinator) stated, I am responsible for updating fall care plans. I have not had time to update (R1 and R3's) fall care plans with their newly developed fall interventions after (R1's) 12-6-23 fall and (R3's) 12-27-23 fall. Residents Affected - Few 146108 Page 2 of 5 146108 01/06/2024 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

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 observation, record review, and interview the facility failed to assess a resident with a history of leaning forward in her wheelchair for safe positioning while in her wheelchair and failed to apply foot pedals to the resident's wheelchair prior to transporting the resident for one of three residents (R1) reviewed for falls with injury in the sample of three. These failures resulted in R1 leaning forward in her wheelchair and abruptly dropping her feet to the floor, which caused R1 to fall face first onto the floor out of her wheelchair, sustaining a three-centimeter laceration to the right forehead that was bleeding and required closure with six sutures in the hospital emergency room. Findings include: The facility's Resident Assessment policy dated 12/2002 documents, It is the policy of the facility to provide a means of determining the physical and mental needs of each resident. Purpose: To define the physical and mental abilities and disabilities and to determine the maximum potential or function of the individual. Evaluation defines needs, problems, approaches short and long-range goals. This composes the nursing care plan. Evaluation is continuous. It begins prior to admission and continues through discharge. 1. Evaluating Persons: Everyone in the resident's environment-physician, family, resident, nurse aide, nurse, activity department, dietary, social service, physical therapy, housekeeping, etc. 2. Importance of evaluation: Good evaluation will result in a good plan of care that effectively meets the resident's needs, thus enabling him/her to attain and maintain his/her maximum functioning level. Poor evaluation will result in a plan of car that does not fully meet the resident's needs, and the attainment of his/her maximum function may not be realized. 3. Nurse Role in Evaluation: Evaluates by communication and observation. Responsible for documentation of evaluation. 4. Areas of Evaluation: A. Physical function of body symptoms. 2. Muscle weakens, complaint of pain in muscles, tightness in ROM (Range of Motion), atrophy, contractures, spasm, rigidity flaccid. 3. Skeletal deformity, arthritic joints, contracture, limited ROM, posture. 12. Activities of daily living-transfer, washing and dressing, gait, and wheelchair mobility. The facility's Accident/Incident Preventions undated policy documents,Physical therapy evaluation as needed for muscle strengthening and balance. R1's Physician Order Report dated 12-5-23 to 1-5-24 documents R1 is an [AGE] year-old with the diagnoses of Dementia with Severe Anxiety, Restlessness, Agitation, and Muscle Weakness. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired. R1's Fall Risk Assessment Tool dated 10-5-23 and signed by V6 (Care Plan Coordinator) documents R1 requires assistance or supervision for mobility, transfers, or ambulation, has a lack of understanding of one's physical and cognitive limitations, and is a high fall risk. R1's Progress Notes dated 12-6-23 at 9:03 AM and signed by V3 (RN/Registered Nurse) document, (R1) was being pushed down hallway from dining room from breakfast in her wheelchair. (R1) leaned forward while wheelchair was being pushed, resulting in (R1) falling out of chair and hitting head on floor. Dime sized laceration noted to middle of forehead, with moderate amount of blood noted. Pressure applied to forehead. Bleeding stopped. (R1) at baseline with cognition. AMT (Advanced Medical Transport) notified to take resident to ER (Emergency Room) for eval (evaluation) and tx (treatment). This 146108 Page 3 of 5 146108 01/06/2024 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 nurse attempted to call POA (Power of Attorney). No answer. Left message to call back. Level of Harm - Actual harm R1's Progress Notes dated 12-6-24 at 9:08 AM and signed by V6 (Care Plan Coordinator) document, Hospice notified of fall and sent out to (hospital). (R1's) right lateral forehead 2.5 (cm/centimeters) by 1 (cm) open area with exposed bone. Area cleansed and ice bag applied. Residents Affected - Few R1's Emergency Department Notes dated 12-6-23 documents, Chief Complaint: (R1) was sitting in her wheelchair and fell forward, hitting her head. (R1) does have a laceration. (R1) is unable to provide any meaningful history. Indication: Presents with a frontal bone laceration. Laceration Repair: Topical anesthetic to forehead. Laceration three cm (centimeters). Six sutures applied. R1's Progress Notes dated 12-6-23 at 5:05 PM and signed by V7 (RN) document, (R1) returned from ED (Emergency Department) with six sutures to right side of forehead. No drainage noted. New order to remove sutures in 7-10 days. R1's IDPH (Illinois Department of Public Health) Final Investigation dated 12-11-23 documents, Incident Description: (R1) is a long-term resident in our facility. (R1) needs assistance from staff with ADLs (Activities of Daily Living). On 12-6-23 at 9:05 AM (R1) had a fall with injury in the hallway. The incident happened after breakfast when (R1) was wheeled down the hallway form the dining room. (V8/CNA/Certified Nursing Assistant) states (R1) was leaning forward and (V8) was bringing (R1's) shoulders back, (V8) got close to the nurse's station and (R1) fell forward and hit her head on the ground. (R1) was assessed immediately by nurses. Noted open area to forehead and moderate amount of blood. Pressure applied and bleeding stopped. One nurse stayed with (R1) while the other nurse made notifications to providers and POA. Order received to send to ER for evaluation and treatment. Staff in-serviced initiated immediately on safe transfers. (R1) returned in the building the same day at 5:05 PM. (R1) obtained six sutures. R1's Fall with Injury Investigation dated 12-6-23 documents, (V8) was pushing (R1) down the hall after breakfast. (R1) leaned forward and fell. (R1) wheelchair did not have footrest. Inservice staff: Wheelchair foot pedals store in the bag for easy access to staff. Foot pedals in place when transporting residents. The Facility's In-Service Education/Meeting Report dated 12-8-23 and instructed by V2 (Director of Nursing) documents direct care workers were in-serviced on ensuring every resident wheelchair needing to have foot pedals and wheelchair foot pedals needing to be in place when transporting residents. On 1-5-24 at 8:55 AM R1 was in a high back, padded, low, four-wheeled chair. R1 was leaning forward during this time and had her feet elevated on the chair's footrest. R1 had a linear pinkish-reddish three cm scab to the right side of her forehead. On 1-5-24 at 9:00 AM V3 (RN) stated, On 12-6-23 (V8/CNA) was pushing (R1) in her wheelchair from the dining room to the common area. (R1) put her foot down abruptly and fell forward out of her wheelchair onto her head. (R1) had a lot of bleeding and a laceration to the right side of her head. There was a lot of bleeding. I applied pressure to (R1's) laceration until the paramedics got to the facility and took (R1) to the emergency room. (R1) had to have stitches. When (V8) was pushing (R1) in the wheelchair, (V8) did not put foot pedals on (R1's) wheelchair which caused (R1) to put her foot down and fall out of the wheelchair. When (V8) was pushing (R1) she should have had foot pedals on her wheelchair. 146108 Page 4 of 5 146108 01/06/2024 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 Level of Harm - Actual harm Residents Affected - Few On 1-5-24 at 9:08 AM V8 (CNA) stated, On 12-6-23 I was pushing (R1) in her wheelchair from the dining room to the common area across from the nurse's desk. (R1) kept swinging her feet and leaning forward numerous times while I was pushing her. I kept grabbing (R1) by the shoulders and trying to pull her backwards. Once I got to about the nurses' station, (R1) put her feet down suddenly, leaned forward, and fell face forward out of her wheelchair onto the floor. (R1) hit her right side of her head and there was lots of bleeding A lot of staff responded immediately and pressure was applied to (R1's) head until the ambulance arrived. I did not put (R1's) foot pedals on her wheelchair that morning and (R1) did not have foot pedals on her wheelchair when I was pushing her down the hallway and should have had foot pedals on her wheelchair. I could not find (R1's) foot pedals that morning. I was educated later by (V2/Director of Nursing) that (R1) should have foot pedals on her wheelchair at all times to prevent (R1) from falling out of the wheelchair. I feel really bad and know I should have put wheelchair pedals on (R1's) chair to prevent her from falling. When (R1) was leaning forward, I should have stopped pushing her and got other staff to assist me in re-positioning (R1). It was common for (R1) to lean forward in her wheelchair all the time even before the day she fell. On 1-5-24 at 10:48 AM V9 (Lead PTA/Physical Therapy Assistant) stated, I know (R1) is non-verbal. If (R1) was leaning forward in her wheelchair prior to the fall on 12-6-23, (R1's) wheelchair positioning should have been assessed by nursing or therapy to try and figure out why (R1) is leaning and to prevent (R1) from falling out of her wheelchair and sustaining an injury. (R1) leaning could have been indicative of (R1) needing to relieve pressure from her bottom, or (R1) trying to walk. No one knows because an assessment was not done. If a resident is not self-propelling a wheelchair, then the resident should have wheelchair pedals on to prevent the resident from putting their foot down while staff are pushing them in their wheelchair. The staff (V8) that was pushing (R1) on 12-6-23 should have stopped pushing (R1) in the wheelchair when she noticed (R1) was leaning forward and swinging her feet. On 1-5-24 at 11:35 AM V10 (CNA) stated, I have worked here awhile and (R1) has always leaned forward while in her wheelchair. I do not know why (R1) leans forward. After (R1's) fall, (V2) in-serviced us (staff) that residents are to have foot pedals on their wheelchairs whenever we are pushing the residents in their wheelchairs. On 1-5-24 at 11:05 AM V2 (Director of Nursing) stated, I in-serviced staff right after (R1) fell out of her wheelchair on 12-6-23. (V8) should have put foot pedals on (R1's) wheelchair when she was transporting (R1) to prevent (R1) from putting her feet down while being pushed in the chair. (R1) has never been assessed by staff or referred to therapy for wheelchair positioning to address (R1) leaning forward in her wheelchair. 146108 Page 5 of 5