Inspection·October 4, 2023

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 interviews and record review, the facility failed to follow their transfer policy. The facility failed to safely transfer a total dependent resident that requires a mechanical lift with 2 person assist, by transferring via stand pivot with one person assist. This affects one resident (R1) of three residents reviewed for safe transfer. This resulted in R1 being hospitalized with a CT scan result of distal tibia periprosthetic fracture and distal fibula fracture. Findings include: Initial Incident Report dated 9/12/23, reads in part: R1 complaint of pain over her right ankle. Noted with anterior swelling and left shin swelling. X-ray done and noted with right ankle mildly displaced fracture of fibula. Left knee with pretibial contusion with uncomplicated Right knee arthroplasty. Investigation initiated. Final report date 9/15/23, reads in part: R1 reported being transferred via stand pivot transfer with onset of pain. Upon receipt of results confirming mildly displaced fracture of fibula R1 was transferred to ER for medical evaluation. admitted with diagnosis of right ankle fracture. Fracture were confirmed via CT of ankle. CNA interviewed and admitted to improper transfer via stand pivot without the use of Hoyer lift as per instructions. CNA aware of transfer instruction and policy. CNA was asked why he did not follow the policy and the instruction for transfer and stated that he thought that he can lift the patient without the use of the machine. CNA stated he made a mistake. CNA terminated. Right Ankle X-ray report dated 9/12/23 shows: impression right ankle x-ray acute to subacute displaced distal fibular fracture. Hospital record reviewed CT scan done on 9/13/23 to compare the x-ray on 9/12/23. CT scan of the right ankle without contrast. Facility record reviewed. Section G (Functional Status) in Minimum Data Set (MDS) dated [DATE] shows: transfer is total dependent with 2 person assist. Care plan initiated on 1/12/23 (R1) requires use of full body lift for transfer related to morbid obesity. Intervention: full body lift with 2 person assist for all transfers. (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: 145683 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 145683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Abington 3901 Glenview Road Glenview, IL 60025 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)