Health inspection·May 26, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, and record reviews, the facility failed to put fall risk interventions in place for 5 residents, (R1 - R5) who are at high risk for falls in a sample of 5. Residents Affected - Some Findings include: On 5/24/23 between 11:35am and 3:33pm, and 5/25/23 between 11:49am and 2:37pm, tours of the facility were conducted and R1 - R5's name plates and wheelchairs did not have indicators on them, identifying them as being fall risks. On 5/26/23 at 8:37am, R1 was observed in his bed with his call light on the floor out of his reach. On 5/24/23 at 3:30pm and on 5/26/23 at 8:49pm R2 was observed in his bed with his bed in a high position. On 5/24/23 between 11:45am and 11:50am, R2 and R3 were observed in the dining room in their wheelchairs with only socks on their feet that were not non-slip/non-skid socks. On 5/25/23 at 11:49am, R3 was in her wheelchair, and she did not have a non-slip pad under the cushion of her wheelchair. On 5/26/23 at 8:44am, R3 was in her room sitting in her wheelchair and her non-slip device was not under the cushion of her wheelchair. R1's 5/18/23 Care Plan showed that R1 is at risk for falls with falls on 5/18/2023 and 5/23/2023. R1's interventions included keep at nurse's station for close supervision. R1's 5/22/23 Fall Risk Evaluation showed R1's score of 17. The fall risk evaluation showed scores above 10 are high risks for falls. R2's 5/27/21 Care Plan showed R2 was a risk for fall with injuries and the care plan showed that on 4/16/22 R2 slipped out of the bed and on 9/25/22 R2 slipped out of the shower chair. R2 care plan showed interventions including anticipate needs, use of appropriate well-fitting footwear, call light within reach, and provide heavier shower chair. R2's 3/9/23, admission Fall Risk Assessment showed a score of 11. The assessment showed that any score above 10 is at high risk for falls. R2's 5/25/23 Physicians Order Sheets showed that R2 is on the blood thinner Clopidogrel 75mg daily. R3's 7/28/19 Care Plan showed that R3 is at risk for falls related to impaired cognition impaired mobility and possible side effects of medication. R3's care plan showed falls on 1/12/22, 3/3/22, 6/5/22, 7/30/22, 3/15/23, and 4/29/23. R3's interventions included non-skid device under wheelchair cushion and use appropriate well-fitting footwear. R3's 3/16/23 Quarterly Fall Risk Assessment showed a score of 13. The assessment showed any score 10 or above is a high risk for falls. R3's 5/25/23, Physician Order Sheets showed that R3 is on the blood thinner Eliquis 5mg daily. R4's 3/10/20 Care Plan showed R4 is at risk for falls related to a history of falls. R4's care plan Page 1 of 2 146170 146170 05/26/2023 Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542

F 0689 Level of Harm - Minimal harm or potential for actual harm showed falls that included injuries on 5/18/23, 7/23/22, 9/23/22, 10/29/22, 4/11/23, and 4/24/23. R4's fall interventions included resident to wear appropriately well fitted shoes, and follow facility fall protocol. R4's 2/11/23 Quarterly Fall Risk Assessment showed a fall risk score of 11. The assessment showed that scores of 10 and above are at high risk for falls. R4's 5/25/23 Physician Order Sheet showed R4 takes aspirin 81 milligrams a day which thins the blood. Residents Affected - Some R5's 5/19/23 Care Plan showed a risk for falls with interventions including anticipate resident's needs, resident to use appropriate well-fitting footwear, call light within reach, evaluate fall risk on admission, and if resident is a fall risk initiate fall risk precautions. R5's 5/18/23 Fall Risk Assessment showed that R5 is a risk for falls. The facility's Fall Prevention Program dated 10/22/22, showed that residents beds are to be lowered to floor allowing residents feet to be flat to the floor, call lights are to be within resident's reach, residents are to be encouraged to wear shoes or slippers with non-slip soles, and place fall prevention indicators (such as stars, color coded stickers) on the name plate to resident's rooms and wheelchairs. The facility's 5/25/23 Form Scoring Report showed R1-R5 at high risk for falls with fall scores between 12-17. The facility's Fall Risk Assessments show that scores 10 and above are at high risk for falls. On 5/24/23 between 11:45am and 11:50am V3 (Nurse) examined R2 and R3's feet and said they are wearing regular socks, they should be wearing non-skid socks or shoes, so they cannot slip or fall. On 5/24/23 between 3:34pm and 3:36pm, V4 (Certified Nurse's Assistant) said that R2-R5 were not fall risks. On 5/26/23 at 8:37am V9 (Certified Nurse's Assistant) said that R1's call light should be within reach, and it should be pinned to his bed. On 5/26/23 at 8:44am, V10 (Certified Nurses' Assistant) said that when she got R3 up she saw the non-slip mat on top of the cushion on R3's wheelchair and she left it that way. On 5/25/23 at 8:52am, V9 (Certified Nurse's Assistant) said, I don't know if R2 is a high risk for falls. If a resident is a fall risk their beds should be lowered so they don't have far to fall. On 5/25/23, at 9:42am, V2 (DON) Director of Nursing said that staff are to look at the Fall Binder that is kept at the nurse's station to know who is at risk for falls. V2 said she saw on 5/24/23 that the facility's Fall Binder, that is kept at the nurse's station did not have a list of the residents who are at risk for falls. On 5/26/23 at 12:24pm, V1 (Administrator) said that the facility fall program shows that residents who are at high risk for falls are to have indicators on their name plates outside of their bedroom and on their wheelchairs, and that residents that are high risks for falls should have their beds to the lowest position, and they should have properly well fitted shoes on, or non-slip/non-skid socks on. On 5/26/23 at 1:02pm, V2 (DON) said that the facility fall program shows that residents who are at high risk for falls are to have indicators on their name plates outside of their bedroom and on their wheelchairs, and that residents that are high risks for falls should have their beds to the lowest position, and they should have properly well fitted shoes on, or non-slip/non-skid socks on. 146170 Page 2 of 2