Health inspection·August 10, 2023

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 - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide safe transfer assistance. This applies to 5 of 9 residents (R1-R5) reviewed for transfers in a sample of 9. This failure resulted in R1 incurring a fracture of the right femur and R3 incurring a fracture of her right humerus. Findings include: 1. R1's Face Sheet dated 8/9/2023 documents R1 as a [AGE] year old with diagnoses to include a right periprosthetic fracture around an artificial knee joint, Vascular Dementia and History of a Stroke. On 8/4/2023 12:15 PM V28 (R1's Daughter) stated she was at the facility on 7/9/2023. After lunch R1 had to use the bathroom and was transferred using a stand assist mechanical lift by V9 (Former Nursing Assistant). V28 stated V9 was the only staff member present completing R1's transfer and V9 did not have R1's legs strapped into the machine properly. V28 stated, typically the girls strap her legs in, and she was not secured against the (leg) plate like she usually is which left too much give. V28 stated the next day (7/10/2023) she adjusted R1's feet in the wheelchair and as she moved R1's right leg she yelled out in pain, and she became less responsive. V5 (Nurse) heard R1's scream, responded and called the paramedics because R1 was not responding as usual. V28 stated as the paramedics were lifting R1 from the wheelchair to the stretcher she again yelled in pain. V28 stated R1 frequently complains of knee pain but her tone and frequency was different this time. R1 continued to complain of knee pain in the emergency room and after continuing to complain of pain on 7/11/2023 in the hospital an X-ray was done, and a fracture was found. V28 stated R1 was initially admitted with pneumonia. On 8/7/2023 at 10:21 AM V9 stated on 7/9/2023 she worked 6 AM-2:30 PM and completed 2 sets of transfers using the stand assist mechanical lift with R1. V9 stated the first transfer was in the morning when she was getting her dressed and out of bed into her wheelchair. V9 stated she used the stand assist mechanical lift to transfer R1 despite being unable to get her left leg positioned on the machine correctly. V9 reported R1's right leg was where it should be, but her left leg was on the left edge of the platform, almost off and not flush. V9 further stated R1's left leg was straight, not bent at the knee so the only leg that was correctly placed was the right and all her weight was placed on her right leg as she was lifted. V9 stated after lunch V28 supervised her while she transferred R1 to the toilet then back to her chair. V9 denied any other issues during the transfers but stated R1 did say, Oh my knee, and she was more quiet and fussy during care when she is normally compliant. The facility Administrator Timeline of Events dated 7/28/2023 documents an investigation was Page 1 of 5 146110 146110 08/10/2023 Smith Crossing 10501 Emilie Lane Orland Park, IL 60467

F 0689 Level of Harm - Actual harm Residents Affected - Some completed, and a discrepancy was identified on a written statement completed by V9. V9 wrote in her statement she was being assisted by V19 (Nurse) for R1's transfers, called off during the investigation and also was a no call, no show causing the facility to be suspicious of V9's behavior. The facility concluded during this investigation that the likely cause of injury to R1 occurred during one of V9's stand assist mechanical lift transfers. V9 was to be terminated but resigned via text instead of reporting to the facility. On 8/4/2023 10:10 AM V3 (Outgoing Director of Nursing) stated the facility was notified of R1's fracture and an investigation was started. R1 did not have any reported falls or incidents that the facility could identify. During interviews with staff, it was identified only one staff was present, instead of the required two when V9 transferred R1 on 7/9/2023. V3 stated V9 is very petite and if R1 had fallen in any scenario V9 would require a second person and a mechanical lift to get R1 off of the floor therefore a fall from the stand assist lift was ruled out. On 8/4/2023 10:10 AM V2 (Interim Administrator) stated I suspect all signs point to something occurring on that shift with that aide (V9). R1's Final Orthopedic Consultative Report completed by V18 (Orthopedic Physician) documents R1 with diffuse bone demineralization and a transverse comminuted fracture of the distal right femur. This fracture is located around the area of a surgical artificial knee replacement completed 10/2011. V18 discussed treatment options with V28, an immobilizer was placed to the right leg and surgery was declined. On 8/9/2023 at 10:37 PM V18 documented in email correspondence R1's type of fracture typically occur from some trauma, likely the result of an injury from a fall, or a twisting mechanism in R1's osteopenic bones. On 8/8/2023 11:30 AM V15 (Physical Therapist) stated all mechanical lifts require 2 staff to be present during the transfer. V15 stated failure to have 2 staff during mechanical lift transfers creates a risk of the resident not being set up properly for the lift, to spot the resident during the transfer, and increases the risk of a fall. V15 stated proper positioning on a stand assist lift includes knees not protruding outward over the feet, body weight should be distributed properly so too much pressure is not placed on the knees, both feet have to be secured on the footboard and knees are to be placed against the leg support and buckled in properly. In addition, proper feet placement reduces the torque and pressure applied during the transfer. V15 stated R1 would not be able to cognitively comprehend to correct her feet placement and the force would have been downward onto her legs if she only had one foot correctly placed during a transfer. V15 stated proper lift technique reduces the chance of injuries and improper technique could have contributed to R1's injury and cause the fracture. On 8/4/2023 at 1:10 PM V6 and V7 (Nursing Assistants) transferred R1 to bed using a mechanical lift. R1 had an immobilizer brace that encompassed a majority of her right leg and she complained of discomfort during the transfer. R1's 5/17/2023 Restorative Nursing Program Evaluation documents R1 as a 2 person assist using a stand assist mechanical lift. R1's Minimum Data Set, dated [DATE] documents R1 with severe cognitive impairments and requiring 2 persons extensive assist for transfers. 146110 Page 2 of 5 146110 08/10/2023 Smith Crossing 10501 Emilie Lane Orland Park, IL 60467

F 0689 2. R3's Face Sheet dated 8/9/2023 documents R3 as a [AGE] year old with diagnoses to include history of left patella fracture, muscle wasting and atrophy and neuropathy. Level of Harm - Actual harm Residents Affected - Some R3's 5/24/2023 Final Report of Resident Injury, dated 5/24/2023, documents on 5/23/2023 R3 complained of bilateral shoulder pain and right arm pain after a stand assist mechanical lift transfer. An X-Ray was completed and showed a fractured right humerus. On 8/9/2023 at 2:08 PM V29 (Agency Nursing Assistant) stated, she transferred R3 on 5/23/2023 with no other staff assisting. V29 stated, It was an unfortunate accident. I wasn't being as cautious as I should have been. I have been a Nursing Assistant since 2008 and have done a sit to stand (stand assist mechanical lift) many times. I was by myself and didn't get the other Nursing Assistant. I didn't have her secured in there as well as I thought. I put her in and lifted her up and as I was moving her to the bathroom, I noticed her foot had slipped off and she slipped down in the lift and she started complaining her arm and shoulder hurt . On 8/7/2023 V12 (Restorative Nurse) stated V29 notified the nurse R3 had slipped during a transfer using the stand assist mechanical lift hurting her arm. R3 was found with a fracture which was consistent with the injury. V12 stated V29 is from an agency and did not have another staff member present as required. R3's Shoulder Radiology Report 5/23/2023 documents R3 with a fracture of the right humerus at the surgical neck (proximal humerus). R3's Physical Therapy Discharge summary dated [DATE] documents R3 is to transfer via a stand assist mechanical lift with 2 staff. 3. R2's Face Sheet dated 8/9/2023 admitted [DATE] with diagnoses to include a total right shoulder replacement, anxiety, and a Stroke. R2's Adverse Event Investigation report dated 6/22/2023 documents R2 lost her balance and fell while being transferred from her bed to wheelchair. Corrective actions document to use a gait belt during transfers. R2's Adverse Event Investigation report dated 7/18/2023 documents R2 lost her balance during a transfer from her bed to wheelchair and the nursing assistant was unable to prevent the fall with the gait belt causing R2 to be lowered to the floor. A Progress Note dated 7/20/2023 documents R2 as noncompliant during transfers, refuses to follow precaution cues while being transferred from bed to wheelchair and wheelchair to toilet, and as having unsteady gait. This note documents V12 (Restorative Nurse) will be notified to follow up. R2's Adverse Event Investigation report dated 7/21/2023 documents R2 lost her balance during a transfer from her wheelchair to bed and the nursing assistant was unable to prevent the fall with the gait belt causing R2 to be lowered to the floor. On 8/7/2023 at 12:11 PM V12 stated R2 is capable of a one person transfer but gets very anxious during transfers. V12 stated R2 needs to go slow and be cued every step of the way. V12 stated she last assessed R2 on 7/18/2023 and was unaware of the progress note on 7/20/2023 to re-assess R2's transfer status. V12 confirmed on 6/22/2023 the nursing assistant assisting with the transfer of R2 was 146110 Page 3 of 5 146110 08/10/2023 Smith Crossing 10501 Emilie Lane Orland Park, IL 60467

F 0689 not using a gait belt as required. Level of Harm - Actual harm On 8/8/2023 11:30 AM V15 (Physical Therapist) stated R2 is able to transfer with one staff member, but because of her anxiety and frequent falls, a second staff member providing assistance during her transfers would likely be able to correct or identify any problems during the transfer and possibly prevent a fall. Residents Affected - Some On 8/4/2023 at 1:00 PM V8 (Nursing Assistant) completed a stand pivot transfer with a gait belt around R2's waist from a wheelchair to a recliner. R2 was slow, required cueing and was hesitant. R2's Restorative Nursing Program Evaluation dated 5/23/2023 documents R2 as a one person extensive assist for transfers. 4. On 8/7/2023 at 1:30 PM R5 was transferred using the stand assist mechanical lift. A Nurse Assistant Post Fall assessment dated [DATE] documents R5 was being assisted by V31 (Nurse Assistant) to transfer from the shower chair to the wheelchair with a stand assist mechanical lift. On 8/7/2023 at 12:11 PM V12 (Restorative Nurse) stated V31 was by herself when she assisted R5 to get dressed after a shower and transferred R5 from the shower chair to a wheelchair. R5 was not able to tolerate standing for that long in the stand assist mechanical lift and was assisted to the floor. V12 stated V31 was by herself and was supposed to have a second staff person to assist. Resident Care Assessment Summary dated 3/31/2023 documents R5 requiring 2 staff to perform a stand assist mechanical lift transfer. 5. R4's Physical Therapy Evaluation dated 6/21/2023 documents R4 was admitted [DATE] for therapy after a microdiscectomy (back surgery) completed 6/16/23. R4 was noted with bilateral lower extremity weakness and the right leg buckled while standing in this evaluation. This assessment documents R4 requiring 2 persons assistance for transfers. A Nurse Post Fall assessment dated [DATE] documents R4 fell during a transfer from the wheelchair to the recliner while being assisted by V30 (Nursing Assistant). This form documents in the future to prevent a fall 2 persons should be used during transfers. On 8/7/2023 at 12:11 PM V12 (Restorative Nurse) stated R4 was lowered to the floor while transferring with one staff member (V30). V12 stated V30 did not follow the care sheet that documented R4 as 2 staff persons assist for transfers. On 8/9/2023 at 9:03 AM V13 (Medical Director) stated she expects the facility to utilize safe transfer techniques to prevent resident injury. The policy Safe Resident Handling dated May 2022 documents staff participating in resident handling and movement shall always practice safer resident handling techniques. This policy further documents gait belts are required for all transfers and the use of a mechanical lift or stand assist lift requires 2 staff to perform the transfer. The policy Accidents and Supervision dated March 2023 documents each resident will receive adequate supervision and assistive devices to prevent accidents. This policy documents specific 146110 Page 4 of 5 146110 08/10/2023 Smith Crossing 10501 Emilie Lane Orland Park, IL 60467

F 0689 interventions are to be implemented to reduce a resident's fall risk, including implementation of specific interventions as part of the resident's plan of care. Level of Harm - Actual harm Residents Affected - Some 146110 Page 5 of 5