Inspection·January 16, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly transfer one resident (R1) and ensure that R1 was wearing proper footwear during the transfer. This failure resulted in R1 being hospitalized and sustaining a fracture to the neck. Findings include: R1 is an [AGE] year old female who admitted back to the facility on [DATE] and was discharged to the hospital on 1/10/2025. R1 has multiple diagnoses including but not limited to the following: type II DM, dementia, psychosis, HTN, dysphagia, difficulty in walking, unsteadiness on feet, disorientation, and need for assistance with personal care. V3's (Licensed Practical Nurse) progress note dated 1/5/2025 at 10:00AM states in part but not limited to the following: V4 (Certified Nursing Assistant) was transferring R1 from wheelchair to the shower chair. V4 said R1 began to slide and was lowered to the floor. R1 was wearing slippers at the time of transfer. On 1/15/2025 at 11:15AM, V4 said I was going to give R1 a shower. R1 was previously a resident here and I was familiar with her. However, this was the first time I had given her a shower since she returned. R1 can transfer independently. R1 was sitting in her wheelchair. I placed her walker in front of her, she stood up using the walker, and I attempted to move the wheelchair and replace it with the shower chair. During the transfer, R1 began to slip and slide down to the ground. She was wearing slippers and she seemed weaker than normal. I assisted R1 in sliding down to the ground. V4 said R1 did not need a transfer belt. A transfer belt is used when a resident cannot mobilize themself. R1 can transfer herself and only needs supervision. It is to be noted that per R1's care plan with initiation date of 12/26/2024 states in part: R1 requires substantial/maximal assistance with 1-2 person assistance to move between services. when transferring. Use gait belt with transfers. Per Minimum Data Set (MDS) dated [DATE] states in part but not limited to the following: R1 requires maximum assistance when transferring into the shower and when going from a sitting to standing position. On 1/15/2025 at 1:41PM, V2 (Director of Nursing) stated R1 required a gait belt when transferring and I would have expected V4 to use one during this transfer. R1 was also wearing her favorite red (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: 145626 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 145626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Generations Oakton Pavillion 1660 Oakton Place Des Plaines, IL 60018 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)