Inspection·February 15, 2024

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 follow their policy and residents' care plans to safely transfer residents. This applies to 2 of 3 residents (R4, R5) reviewed for falls in the sample of 5. The findings include: 1. On February 14, 2024 at 9:44 AM, R4 was sitting up in a wheelchair in her room. No injuries were visible on the resident. R4 was unable to answer questions due to her cognitive status. The EMR (Electronic Medical Record) shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, cellulitis of the left lower limb, lack of coordination, muscle weakness, cognitive decline, repeated falls, spinal stenosis, osteoporosis, dementia, heart failure, and overactive bladder. R4's MDS (Minimum Data Set) dated December 27, 2023 shows R4 has moderate cognitive impairment, is independent with eating, requires substantial/maximal assistance with oral hygiene, showering, and personal hygiene, and is totally dependent on facility staff for toilet hygiene, lower body dressing, bed mobility, and transferring from the bed to the chair, the toilet, and the shower. R4's care plan initiated on November 16, 2023, and revised on January 24, 2024 shows: The resident requires max assistance with the use of sit-stand machine by (2) staff members for all transfers. R4's Fall Incident Report dated February 2, 2024 at 8:45 AM shows: Writer received report that resident slipped from sit-to-stand while being transferred from the toilet. Resident was observed sitting on floor of bathroom in front of toilet. No noted injuries at this time. Resident was assisted up from floor and back to wheelchair with two staff members. Resident stated that her legs gave out and she was unable to stand up. There were no complaints of pain during ROM (Range of Motion) to bilateral legs. R4's incident report shows R4 did not sustain an injury due to the fall. On February 13, 2024 at 11:02 AM, V2 (DON-Director of Nursing) said R4 uses a sit-to-stand mechanical lift for transfers between surfaces and was being assisted to transfer with a sit-to-stand mechanical lift on February 2, 2024. V2 said, V3 (CNA-Certified Nursing Assistant) owned up to being alone during the transfer. A few days before the incident we had done a house-wide in-service of all staff with a restorative aide explaining how all residents need two staff members present when using a mechanical lift, and [V3] did not follow the instructions. V2 continued to say, [V3] should have (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: 145522 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 145522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Hill 2400 South Finley Road Lombard, IL 60148 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)