Health inspection·January 7, 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 staff safely assisted and supervised a resident while showering. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's face sheet shows he is a [AGE] year-old male admitted to the facility on [DATE]. R1's diagnoses including neoplasm of the brain, muscle weakness, aphasia, cognitive communication deficit, history of falling, cerebral infarct, and unspecified convulsions. R1's Minimum Data Set assessment dated [DATE] shows severe cognitive impairment, has limited range of motion with impairments to one side affecting his upper and lower extremity, and dependent on staff for showers/bathing. On 01/07/25 at 9:49 AM, R1 was observed in a high back wheelchair located near the nurse's station in the hallway. R1 was leaning forward and back repeatedly in his wheelchair. R1 was alert to self only. R1 said he fell but does not recall the details of the fall. On 01/07/25 at 9:52 AM, V3 (Registered Nurse/RN) said R1 is alert to self with right sided weakness. He leans forward when he is in his wheelchair this is normal for him. She was R1's nurse the on 12/27/24 when he fell in the shower room. She was notified by V4 (Certified Nursing Assistant/CNA), R1 fell in the shower room. V4 reported while he turned away from R1 to get his clothes, R1 fell forward out of the shower chair. R1 needs close supervision and should have two staff while showering R1. On 01/07/25 at 10:02 AM, V5 (CNA) said R1 has right sided weakness, he transfers and showers with two person assist. R1 is alert to self but does not answer questions appropriately or understand what you are saying. R1 has always been a two person assist during showers because he is weak, unsteady and at risk for falls When giving a resident a shower, staff should ensure items are within close reach. On 01/07/25 at 11:49 AM, V4 (CNA) said he was R1's CNA on 12/27/24. He was told R1 was a two person assist for showers, R1 was a newer admit and had not given him a shower prior. He transferred R1 from his bed to the wheelchair and wheeled him to the shower room. R1 was not steady during the transfer from the bed to the wheelchair. After showering R1, he turned his back away from R1 and reached for a towel and R1's clothing placed on the shower bench against the wall. When he turned around, R1 was leaning over in his shower chair and fell on the floor. He was cueing R1 directions to stay Page 1 of 2 146136 146136 01/07/2025 Radford Green 960 Audubon Way Lincolnshire, IL 60069

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few still, but he was not sure if R1 understood him. V4 said he used a regular shower chair and did not dry off R1 yet with the towel. V4 said he felt confident enough to give R1 a shower himself. V4 said he should have placed the items closer in reach. R1's current care plan shows he is at risk for falls with interventions to be assisted in shower x 2 until reclining chair is available. The facility's Final Investigation dated 12/28/24 documents on 12/27/24, (V4 CNA) was assisting a (R1) with a shower. (V4) turned to grab the clothes off the other chair when (R1) leaned forward and fell to the floor .due to weakness and trunk control resident will be assisted x 2 until a reclining shower chair is available. The facility's Falls Protocol undated policy states, the staff will document risk factors for falling in the resident's record and discuss the resident's fall risk .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 146136 Page 2 of 2