Health inspection·November 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 the facility protocol to safely operate a full body mechanical lift by failing to use 2 staff persons when transferring a patient to a wheelchair from bed. This affected one of three resident (R1) reviewed for mechanical lift. This failure resulted in the full body mechanical lift tipping onto the floor and R1 falling to the floor, while still hooked by the sling to the lift. findings include: R1 incident report dated 11/1/24 states writer heard R1 yelling help. Writer observed R1 on the floor with the full body mechanical lift on the floor next to the resident. R1 complained of lower back pain, rated 10. R1's diagnosis include but are not limited to Encounter for Orthopedic Aftercare, Heart Failure, Atrial Fibrillation, Peripheral Vascular Disease, Chronic Kidney Disease, End Stage Renal Disease, Pain in Left hip, Displaced Fracture of Left Femur. On 11/8/24 at 10:13AM V8, R1's family, said R1 said the facility called me about 7:30AM. V8 said they said R1 was getting up for dialysis that morning and had a fall. V8 said they told me I didn't need to come in, but I came right in and R1 told me the mechanical lift fell on her. V8 said the whole time R1 said she was in pain, she had head and back pain. V8 said R1 said she hit her head. On 11/8/24 at 1:58PM V7, CNA, said on 11/1/24 I was getting R1 ready for dialysis that morning. V7 said instead of getting someone to help spot me, I just did it. V7 said R1 was cooperative during the transfer, she was fine. V7 said I had R1 in the lift, and as it was going up it was not correct, I should have had someone there to spot. V7 said R1 was up in the air over the bed and as I was going towards the dialysis chair, moving to the chair, as lowering it, it happened quickly. V7 said I was turning it a little, I was getting ready to turn, getting over the chair, and as I was lowering R1 the fall occurred. V7 said everything went straight down. V7 said nothing came undone, R1 remained connected in the sling. V7 said V6, LPN, came in the room. V7 said we had to straighten the lift up, it was on one of the sides. V7 said R1 was all shook up. V7 said I am supposed to get a second person, a spotter, always, I did not on that day. V7 said I knew better that morning. V7 said I was just trying to get done. V7 said I have been inserviced yearly on the use of lifts. V7 said I would have to search for someone to help me. V7 said we used the same lift and put R1 back to the bed. V7 said V6 came and helped. V7 said R1 was all shook up. V7 said after the fall R1 was apologizing to me while we were putting her back to bed. (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 3 Event ID: 145734 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Evergreen Park 10124 South Kedzie Evergreen Park, IL 60805 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)