Health inspection·November 19, 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 interview and record review, the facility failed to ensure a resident was safely turned and positioned during incontinence care for 1 of 4 residents (R1) reviewed for safety and supervision in the sample of 4.The findings include: R1‘s admission Record, dated 11/19/25, shows R1's diagnoses include, but are not limited to type 2 diabetes, morbid obesity, presence of a cardiac pacemaker, hypertension, polyneuropathy, restless and agitation, and a history of falling.R1's Minimum Data Set, dated [DATE], shows R1 has impairment to her functional range of motion on one side to her lower extremity (hip, knee, ankle, foot), has moderate cognitive impairment and is dependent (meaning the helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity.) on staff to provide toileting hygiene and to roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed.).R1's current care plan provided by the facility shows R1 has ADL (activities of daily living) self-care performance deficits and limitations in physical mobility and has a history of being resistant to care such as refusing to be changed, uncooperative and resistant to treatments due to agitation. R1's care plan shows she is at high risk for falls due to her debility/need for assistance with ADLs and acute illness.R1's Progress Notes written on 11/17/25 at 1:45 AM by V6, Licensed Practical Nurse (LPN), shows the CNA, V7, called V6 to R1's room where R1 was lying on her left side on the floor on the right side of the bed. V6 said she was told by V7 the following, while changing this resident, I positioned her on her right side, and told her not to turn any further, I proceeded to clean her when I noticed she started sliding down the right side of the bed, so I grabbed the draw sheet in an attempt to prevent her from falling but I was unable and instead assisted in guiding her down to the floor, she landed on her left side without hitting her head.The facility's State Report regarding R1, dated 11/19/25, shows R1 had a witnessed fall on 11/17/25. It shows R1 has a history of falling and non-compliance with medication and refusing treatment and care.R1's After Visit Summary from the hospital, dated 11/17/25, shows R1's height is five feet five inches, and her weight is 283 pounds 4.7 ounces. R1 had a CT scan of her cervical spine, abdomen, pelvis and head and x-rays of her left knee and was diagnosed with a fall.On 11/19/25 at 9:57 AM, R1 said on Monday night (11/17/25) around 1:30 AM, a female CNA (Certified Nursing Assistant) whose name she cannot remember was changing her. R1 said the CNA, later identified as V7, was rolling her onto her right side and all the sudden said, Don't move, or you're gonna (sic) fall off the bed and no sooner than she said it, she had already fallen out of bed onto her knees. R1 said she didn't actually fall, she was pushed. R1 said V7 called for help and a nurse came. R1 said she was taken to the hospital, and she returned the same night with a bruised knee. R1 showed her left knee which had a light green half dollar coin sized bruise. R1 said there were no fractures or other injuries.On 11/19/25 at 12:06 PM, V5, CNA, said R1 is a two assist for turning in bed; she is heavy.On (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: 145460 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 145460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Lake County 850 E US Highway 45 Mundelein, IL 60060 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)