Health inspection·January 22, 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 provide safe transfer to a resident (R1) while using a mechanical transfer total lift device. This applies to 1 of 3 (R1) residents reviewed for transfer using a mechanical transfer total lift device. The findings include: The EMR (Electronic Medical Record) showed that R1, an [AGE] year-old, with diagnosis that included dementia, with moderate psychotic behavioral disturbance, chronic obstructive pulmonary disease, seizure, depressive disorder, abnormalities of gait and mobility, lack of coordination, Lewy Body Disease, aphasia, anxiety and paranoia. R1 was admitted into the facility on July 31, 2024. The MDS (Minimum Data Set) dated November 8, 2024 and January 5, 2025 showed that R1's cognition was moderately impaired. R1 also required maximum/dependent with staff ADLs (Activities of Daily Living). The care plan dated October 21, 2024 showed that R1 requires mechanical transfer total lift device with two-person assist for transfer for bed to wheelchair and vice versa. The facilities' incident report dated October 27, 2024 showed that during early morning care, R1 was noted with a cut and discoloration around his right eye. Further review of the facilities' incident report showed that R1 sustained this injury due to unsafe transfer while using a mechanical transfer total lift device on October 26, 2024 at approximately 7:30 PM. This transfer was done by V3 (CNA/Certified Nursing Assistant). On January 21, 2025 at 11:30 AM, V1 (Administrator) said that V3 had improperly transferred R1 on October 26, 2024 at 7:30 PM by not following the facilities' policy. V1 further explained that two-person assist is required when mechanical transfer total lift device is utilized. However, with this case, it was only V3 that transferred R1. V1 also added that due to the unsafe transfer R1 sustained a small cut and bruise around right eye. V1 also said that V3 had said he was the only one who transferred R1 to bed on October 26, 2024 around 7:30 PM. V1 further said that V3 was terminated for not following facilities' policy. On January 21, 2025 at 12:20 PM, V7 (CNA) mentioned he took care of R1 during day shift on October 27, 2024. V7 also said that prior to getting up R1 from bed, she noted R1's small cut and bruising around the right eye. V7 said there was no fall that was noted to R1. On January 21, 2025 at 12:25 PM, V6 (RN/Registered Nurse) said that he took care of R1 on October 26, 2024. V6 said that R1 slept throughout the night and there were no unusual occurrences or falls. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145213 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145213 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wynscape Health & Rehab 2180 Manchester Road Wheaton, IL 60187 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)