Inspection·May 2, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few floor, R1 again nodded her head in the up and down motion. The nurse placed the dressing back on R1's knee. R1 was thanked for her time and observation. On 4/28/23 at 10:42am V2 (Nurse) said she was the nurse on duty when R1 was assisted to the floor by the CNA. V2 said V3 (CNA- certified nursing aide) informed her that she was changing R1 (providing incontinent care), and she turned R1, and R1 began to slide out of the bed, and so she assisted R1 to the floor. V2 said when she went to the room to assess R1 she noticed R1 with a skin tear to the left knee. V2 said she don't know what R1 hit her knee on to cause the skin tear. V2 said after assessing R1, R1 was lifted with a bed sheet and placed back in the bed. V2 said the physician and family was notified and orders were given. On 4/28/23 at 11:07am V3 (CNA-certified nursing assistant) said she was an agency CNA staff, and she was responsible for R1 care on 4/23/23 (morning shift). V3 said she had provided incontinence care to R1, and she was changing the sheet on the bed when R1 began to slide out the bed. V3 said she assisted R1 to the floor. V3 said R1 was in the middle of the bed when she turned R1 to the left (away from the wall and bed rail) to change the sheet. V3 said she was standing on the left side of the bed also. V3 said R1 has a new mattress, and it has bumps in it (air mattress) and that's why R1 was sliding. V3 said R1 began to slide, and her instincts was to catch R1 and bring R1 to the floor. V3 said the best thing was to gently bring R1 to the floor. V3 said she saw the abrasion to R1 left knee and she really believe it came from the carpet when she lowered R1 to the floor, but she can't be 100% certain. V3 said she was the only person assisting R1 at that time with incontinent care and bed mobility. V3 said she got report that R1 needed extensive assist, but no one informed her of how many physical assist that R1 needed. On 5/1/23 at 11:35am V4 (restorative nurse) said when turning R1 the staff should inform the resident that care is going to be provided inform R1 that she will be asked to assist with the turn by holding the assistive devices if she can. V4 said because R1 legs are contracted, R1 legs should be adjusted for comfort and to allow for the turning. R1 should be cued to assist as appropriate, ensure that R1 is in the middle of the bed initially, then pull R1 body to the opposite side of the turn, use the bed pad to assist with the turn (hold the bed pad near bottom and near back of patient), lift and push simultaneously to turn R1 onto the side. V4 said R1 has assistive devices used for bed mobility. V4 said R1 require extensive assist with 1-to-2-person physical assist with bed mobility. V4 said the staff has been in-serviced. On 5/1/23 at 3:25pm V7 (therapist) said R1 needs 2-person physical assist with bed mobility for turning and repositioning this is for safety, and this is because of the incident. V7 said the goal is for R1 to have one person assist with bed mobility. V7 said part of what therapy does is care giver education and so today he demonstrated to the facility on how to turn and reposition R1 with one-person physical assist. On 5/1/23 at 11:30am V5 (Administrator) said V3 has not being back to the facility to be in-serviced on facility practices, however all other CNA has been in-serviced. V5 said the facility has identified the root cause analysis was the position of R1 when R1 was being turned, V5 said R1 care plan has been updated, the air mattress is in place as a preventive measure for skin integrity. V5 said R1 family did receive an update on the incident. R1 MDS dated [DATE] denotes in-part that R1 requires extensive assist with 2 plus person physical assist with bed mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145731 If continuation sheet Page 2 of 3 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 145731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel at Saint Benedict 6930 West Touhy Avenue Niles, IL 60714 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Facility CNA competency assessment, make occupied bed denotes in-part identify patient (safety) greet patient, explain procedures; provide privacy (residents rights), place bed in appropriate position, position resident on one side of the bed, utilize assist device if applicable, tuck dirty linen on first side, reposition resident to other side, remove soiled linen and complete tucking in bottom linen and dispose soiled linen, reposition resident to comfortable position. Residents Affected - Few Facility policy titled safe lifting and moving of patients, with last approve date of 01/2022 denotes in-part in order to protect the safety and well being of associates and residents, and to promote quality care, this community uses appropriate techniques and devices to lift and move residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145731 If continuation sheet Page 3 of 3