Inspection·August 5, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based upon observation, interview, and record review the facility failed to follow policy procedures and failed to revise comprehensive care plans with preventive interventions to ensure resident safety for two of three residents (R3, R4) reviewed for injury of unknown origin. Findings include: 1. R3's (7/3/24) facility reported incident includes x-ray of right-hand: non-displaced fracture of the proximal third phalanx. (R3) is a poor historian due to diagnosis of dementia, so he is unable to give account of the fracture. When asked how he (R3) sustained the fracture, he pointed at the bedside table. On 7/5/24 while being interviewed, (V2/Director of Nursing) observed (R3) suddenly swing the affected hand but the side table was not in close proximity, otherwise the hand would have hit the table. It is concluded that the injury is a result of (R3) bumping the affected hand on his bedside table when he swung the right hand. R3's (7/9/24) care plan includes risk for injury related to poor safety awareness due to dementia. Resident noted with acute fracture of right 3rd finger as a result of bumping his bedside table when he swung his right hand. Interventions: administer pain medication as ordered. Call for follow-up appointment with plastic surgery, monitor the injured area for pain, swelling and other symptoms. [preventive interventions are excluded]. On 7/29/24 at 3:03pm, R3 was observed seated in the hallway with a bedside table placed above his lap. Surveyor inquired how R3 injured the right finger V6 (Licensed Practical Nurse) stated I don't know, I can't speculate. On 8/1/24 at 1:46pm, surveyor inquired about care plan requirements, V9 (Care Plan Coordinator) stated As soon as the team find out that there's an incident, we'll start to look at the care plans in the meeting. During that meeting, if there's interventions that need revised or added we do it at that time. Surveyor inquired if R3's (7/9/24) risk for injury care plan includes preventive interventions V9 responded Yes. We monitor the injury for pain, swelling, and other symptoms so before it gets worse, we already had monitored it [none of which will prevent injury]. Surveyor inquired how R3 injured his hand, V9 replied He (R3) bumped his hand on the bedside table. Surveyor inquired how the facility will prevent further injury to R3, V9 stated We have to assist the patient and make sure that he's not gonna bump anything. Surveyor inquired if assisting resident was on R3's risk for injury care plan, V9 responded No. Surveyor inquired why preventive measures such as assist the patient and/or moving the bedside table out of reach were not on R3's risk for injury care plan, V9 replied Honestly now that you told me, that's the first thing I'm thinking right now. It should be added. (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 4 Event ID: 145679 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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)