Inspection·June 10, 2024

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 safely transfer a resident with a mechanic lift. This failure resulted in staff transferring R2 to bed from wheelchair via mechanical lift, during the transfer R2's left foot bumped the footboard which resulted in fracture to the left distal tibia. This failure affected 1 resident (R2) in a sample of 5 reviewed for accidents. Findings include, Facility's reportable to state agency (4/29/24) documents in part: R2 was observed by floor nurse exhibiting s/s (signs and symptoms) of pain. PRN (as needed) pain medication given and effective. MD (doctor) made aware and gave an order for x-ray. The X-ray showed a fracture to the left distal tibia. Family and MD made aware, orders received to transfer resident to the ED (emergency department) for further evaluation and treatment. Family made aware of transfer. Upon investigation it was found that on 4/26/24 V14 (CNA) stated that as she and V13 (CNA) were transferring R2 to bed from wheelchair via mechanical lift. During the transfer, R2's weight shifted causing her left foot to bump the footboard. R2 was safely positioned in bed, and V12 (LPN) was summoned to assess R2. V12-V14 all stated that R2 did not complain of pain or discomfort at this time. V12 stated that she assessed R2 and noted no visible signs of injury no bruising, redness or swelling and no skin alterations to that area. V13 and V14 went on to assist R2 with ADL (incontinence care) care in bed and R2 still did not display any signs of discomfort. R2 rested comfortably in bed for the rest of their shift. R2 was assessed for pain every shift, daily, with out change until 4/29/24. On 4/29/24 Staff nurse noticed the area to be tender to touch. PRN pain medications given with effectiveness. Ice pack applied and leg elevated. MD made aware with order for x-ray. Family notified. X-ray results showed fracture of distal tibia. MD made aware with order to send R2 out to hospital for evaluation and treatment. Family made aware. R2 remains in the hospital at this time and plan of care will be updated upon her return. R2 was alert and oriented with a BIMS (Brief Interview for Mental Status) of 9 (meaning moderately impaired). R2's diagnosis included but are not limited to: Altered Mental Status, History of Falling, Difficulty in Walking, Muscle Weakness. On 6/8/24 at 9:25 am, V12 (Licensed Practical Nurse ) said she recalls the incident. V12 said, on 4/26/24 she (V12) and V14 (Certified Nursing Assistant) were assigned to R2. V12 said, V14 came and got her and said that upon transferring R2, her foot hit the foot board, she assessed the resident and there was no pain, no bruising was noted and that was it. V12 said, she does not recall writing a progress note about this incident. V12 said, with mechanical lifts there needs to be 2 people. When asked V12 should this incident be reported to V2 (Director of Nursing), V12 said no, because R2 (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: 145779 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 145779 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463 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)