Health inspection·June 6, 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 interviews and record reviews, the facility failed to maintain resident safety during resident transfer from regular bed to bariatric bed using bed sheet. This deficient practice affects one resident (R1) of three residents reviewed for incident and accident. R1 was sent out to local hospital due to right hip pain not relieved by prescribed pain medication. R1's hospital x-ray result shows right hip acute right proximal femoral fracture. Findings Include: R1 was admitted in the facility on 4/19/24. R1 has diagnoses of but not limited to: acute and chronic respiratory failure with hypercapnia, Type 2 Diabetes, Morbid Severe Obesity, Heart Failure, Hypothyroidism, and Obstructive Sleep Apnea. On 5/31/24 at 10AM, interviewed R1 via phone and R1 reported R1 was at the facility for 2 days. R1 said R1 has been refusing to be turned due to pain, and stated R1 has no cartilage left in R1's hips and knees. R1 does not want to be turned due to R1 has certain ways they like to be turned in bed, R1's own preferred way. Five staff were turning R1 to be transferred to bariatric bed. Five staff members assisted with transfer. R1 reported she was transferred to bariatric bed with bed sheet. R1 does not recall names of staff who were assisting. R1 stated that R1's left leg was crossed over in front of R1's right leg and R1 heard a cracked on her right hip. R1 felt pain. The worst pain in the world. R1 does not recall if R1 received pain medication and if R1 did R1 stated the medication did not work and R1 continued to have pain. On 5/31/24 at 12:36PM, V5 (CNA) stated that R1 was transferred to bariatric bed during V5's shift on 4/20/24. V5 was not assigned to R1 but staff needed help because R1 was a big lady. Six staff members were present for transfer. When V5 arrived in R1's room they observed other CNAs and the nurse encouraging her to be transferred, explaining to R1 how the transfer will be done. R1 said NO, you can't I am too heavy, you guys can't do it. My leg is broken. You cannot touch this leg. Staff continued to explain to R1 that they will not touch the leg, explaining to R1 that we just have to slide R1 from one bed to another bed, using the bed sheet. R1 continued to scream No, and finally we are able to convince R1 to be transferred. R1 finally said yes. R1 was lying flat, staff did not reposition the leg. The leg was straight, and staff did not touch it. On 5/31/24 at 2:30PM, V7 (RN) stated that they were not the assigned nurse for R1 but was present in the room during transfer, there were two nurses and four CNAs transferring R1 with bed sheet. Staff offered mechanical lift and R1 refused. Two staff were on one side and three on the other side and one on the bottom. R1 was slide it to the other bed. R1 was in supine position when transferred. Once transferred to the new bed, V7 saw R1 was still laying on the hospital linen with the mechanical Page 1 of 3 146176 146176 06/06/2024 Celebrate Senior Living Niles 7000 North Newark Niles, IL 60714

F 0689 Level of Harm - Actual harm Residents Affected - Few pad from the hospital. I was one of the staff that pushed the sheet and noted that my uniform got wet. The linens were soaking wet. Staff talked to R1 that we have to remove the linens and R1 agreed for the removal of linens and was assisting the staff at first by lifting herself up but was not able to continue because R1 was heavy. We suggested that we have to turn her a little bit on her side, and R1 agreed. Staff were holding onto a pad to turn R1 a little on her side and staff pulled the hospital linen out. Staff were able to remove maybe three linens and there were more. R1 yelled to put her back, my legs, my legs are hurting, put me back. R1 was upset, saying that we don't know how to take care of people. We put R1 back to the supine position like the way R1 was before. R1 already was with pain before, and after we did not think the pain was new from the transfer. We did not hear any cracking sound during the care. On 5/31/24 at 1PM, V6 (RN) stated V6 was the assigned nurse on 4/20/24 when R1 was transferred from regular bed to bariatric bed. V6 stated that after dinner, bedtime came and V6 explained to R1 that R1will be transferred to the new bed. R1 was not allowing us to transfer R1 because of pain. R1 was told a mechanical lift will be used and R1 refused. R1 said R1wants to be transferred by sheet instead. Six people assisted with transfer: sliding R1 to another bed. The beds were right next to each other. R1 was laying supine in flat position. After the transfer, R1 had no complaint of pain; but during med pass around 5-530 R1 complained of pain on both legs. 2 Tylenol were given, and they were effective. R1 reported less pain, a little bit of relief. No more complaint of pain. V6 stated V6 reported to Nurse Practitioner, and they started gabapentin and other medication. I do not recall which PRN (as needed) medication was given; but recall giving her PRN, 2 Tylenol. V6 stated that V6 was also the nurse for R1 on 4/21/24 afternoon shift. During med pass R1 complained of leg pain. V6 then called V13 (Nurse Practitioner) and made them aware of more pain and R1 does not want to have care provided. V13 ordered to send R1 to the hospital. I was the nurse that sent R1 out to hospital. We were at the time still waiting for the x-ray result. Result was not yet available when NP was called. On 6/4/24 at 10:40AM, V12 (LPN) stated that V12 worked when R1 was already admitted in the facility. V12 worked 2 consecutive days for R1 in the morning shift. On 4/20/24 end of shift R1 complained of right leg pain. Norco for pain given and was effective. Next day (4/21/24) V12 was the nurse of R1 and R1 complained of right hip pain not relieved by pain medication (Norco). V12 called NP (Nurse Practitioner) and V12 ordered right hip x-ray 2-3 views stat. The X-ray came in before 2pm, close to the end of V12's shift. Progress note dated 4/21/2024 at 1:06PM, reads in part: R1 complaint of pain to right hip with scale of 8/10 and didn't relieve with prescribed pain medicine. Nurse Practitioner made aware with new order for Pelvis and right Femur x-ray 2-3 views Stat (immediately). Progress note dated 4/21/2024 at 10:03PM, reads in part: R1 was complaining that R1 is in lot of pain around the buttock area and R1 was refusing all the care from CNAs. R1 did not want anybody to touch her saying she is in lot of pain. There was a barrier in cleaning R1 and her bed since R1 was constantly refusing all care. Writer informed the situation to NP. NP ordered to send R1 to hospital. Gave report to ER (Emergency Room) nurse. On 6/4/24 at 11AM, V2 (DON), stated that R1 was admitted using a regular bed and reported that the bed was uncomfortable. Facility ordered bariatric bed. Bed was delivered the next day. Staff offered R1 the mechanical lift and R1 refused. R1 okayed the transfer with the bed sheet. There was nothing unusual during the transfer to bariatric bed, and at that time R1 was observed with feces and staff attempted to clean her. Staff lifted R1's left side buttock to remove and wipe the feces. Staff were able to clean some but R1 said she was in pain and staff stopped cleaning R1. 146176 Page 2 of 3 146176 06/06/2024 Celebrate Senior Living Niles 7000 North Newark Niles, IL 60714

F 0689 Level of Harm - Actual harm Residents Affected - Few On 6/5/24 at 12:38PM, V13 (NP) stated that the nurse called V13 and said that resident was complaining of pain, refusing care, and does not want to be moved. V13 stated she knew R1 was already taking narcotics in the hospital and since admission to the facility; and that this pain is not new to R1. V13 ordered X-ray to rule out fracture, due to R1's pain and refusal to be moved. V13 said that there is a suspected fracture and ordered for R1 to be sent out to local hospital for further evaluation. Proximal femur fracture can happen due to trauma: such as fall, mishandling of the patient during patient care, or the patient herself can cause this fracture. Immobility can lead to osteopenia, osteoporosis and can cause fracture. Hospital record dated 4/21/24, reads in part: Chief complaint: Hip Pain. R1 reports that R1 has chronic pain in R1's hips and knees due to bone on bone osteoarthritis but that last night the SAR staff moved R1 too roughly, they folded me like a pretzel and since then she has 10/10 hip pain on the right. R1 had X-ray and showing right hip diffusely demineralized bones and acute right proximal femoral fracture. Mechanical lift transfer policy not dated, reads in part: purpose: to assist the resident with mechanical lift transfer when clinically indicate, to provide increased security for the resident and staff, and to prevent injury during transfer. Standard: Residents should be assisted to transfer using mechanical list when clinically indicated. Accident/Incident Management and Reporting policy not dated, reads in part: Accident and incident are an occurrence affecting a resident that is not the expected outcome of a resident's condition or disease process. Examples include but are not limited to falls or observed on floor, burns, skin tears, bruises, alterations, injuries of unknown origin, and attempted elopement. An accident or incident is an unexpected, unintended event that can cause a resident bodily injury. 146176 Page 3 of 3