Health inspection·May 26, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few Interview with V8 (Certified Nursing Assistant/CNA) on 5/26/24 at 2:26PM, V8 stated, I've worked at the facility for a year and four months; I work on both (shelter and skilled) floors. (On 2/11/24) I was working with two agency CNA's that day. I was the only regular staff on the floor that day. I was trying to help everyone out because they don't know the residents, they don't know how they like things, transfers, etc. R1 was not assigned to me that day but the agency CNA needed help transferring her, so I went to help her. If I remember correctly, there were actually two agency plus one trainee (CNA's), but the trainee never came back after that. I think that was her first day. I have worked with R1 before with therapy, so I said I know how to get her up. I went in the room and told her I was going to get her up for lunch. I didn't look at the page because I knew I had done it before with therapy. She usually gets up and we helped her, and she scooted on the side of the bed, we put the belt and the walker in front of her. She would grab the walker and stand and walk a few steps forward. But this time she did everything good but the only thing that went wrong was turning. She did stand and she grabbed the walker. I was in front, and the other CNA was on the side. She did stand and twist her body, but she did not move her legs. So, she failed to pivot. We didn't want her to fall, so she grabbed her from the back and swung her onto the wheelchair. I don't know if the wheelchair was too small, and her legs were too big. We sat her on the chair but then her leg got caught on the wheelchair. Nothing was out of the ordinary but the only thing that failed was the pivot. I didn't know at that moment since I had not worked with her for a while. I didn't know she was supposed to use the mechanical lift and I didn't know because no one told me, and I didn't see any (mechanical lift) pad in her room. I would have done the transfer with the mechanical lift if I had known but they didn't tell me until after the fact. V8 stated that staff normally know the residents' transfer status by looking at the binder at the nurses station but added, that she didn't look at it prior to transferring R1. V8 said that after the incident happened, she looked at the binder and saw that R1 should have been a mechanical lift transfer. V8 said, we need to look in the book to see if there are changes in resident status and ADL (activities of daily living) needs. Interview with V8 confirms information provided in CNA Occurrence Report completed by V8 on 2/11/24. On 5/24/24 at 12:36PM, V9 (Registered Nurse/RN) said that R1 is oriented times one or two with confusion. R1 is extensive assist and uses a wheelchair and mechanical lift for transfers. V9 said, we can't safely transfer her without the mechanical lift. She has needed the mechanical lift for at least two or three months that I can recall. She always requires two persons for transfer. On 5/25/24 at 1:59PM V6 (CNA) was interviewed and confirmed that there was a previous incident with R1, where she obtained an injury during a transfer but there was nothing done incorrectly, the issue was just that her skin is very sensitive. V6 said it was normal for R1's legs to be swollen and that R1's skin is very sensitive and easily to tear. V6 said, we always use a mechanical lift with her. The only incidents with her is her skin. On 5/24/24 at 2PM, V2 (Director of Nursing) said, the incident with R1 in February was a witnessed event, they had removed the leg rest. R1 didn't pivot her leg. She was doing therapy at that time. After this point, we made her a mechanical lift. At that point she would only ambulate with therapy; we (nursing) were no longer cleared to ambulate her due to her lack of consistency. It was a safety issue for her. On 5/25/24 at 2:08PM, V2 confirmed that during the incident with R1 in February, staff were not using the mechanical lift, they were doing a two-person pivot transfer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145786 If continuation sheet Page 2 of 5 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 145786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincolnwood Place 7000 North McCormick Blvd. Lincolnwood, IL 60645 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 - Actual harm Residents Affected - Few On 5/25/24 at 12:46PM, V10 (RN) was interviewed and stated that she did not recall much about the incident with R1. V10 said that she recalled that staff were present and that R1 obtained a skin tear. V10 confirmed that R1 requires two staff for transfers. Review of Incident Detail report completed by V10 (RN) for incident of 2/11/24 reads, under Description of Incident: two staff were assisting with a PIVOT transfer from wheelchair to bed. Leg rests were removed, wheelchair locked and positioned next to bed. Staff were able to stand resident and cued resident to pivot transfer and sit on edge of bed. Resident upper body pivoted leaned onto bed, when staff realized that lower extremity did not pivot, she sustained a laceration from the lower part of wheelchair. Staff assisted into bed and immediately notified nurse. Nurse assessed resident and sent out 911. Res returned to facility with 12 sutures to left lower leg. Review of R1's Physical Therapy - Therapist Progress & Discharge summary dated [DATE] reads - Start of Care 12/14/23 and End of Care 2/9/24 Functional Deficits - Current Level for Transfers Mobility, E. Chair/bed to chair transfer requires, Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort; Goal for patient to safely transfer from bed <> wheelchair requiring maximum assistance x 2 (76-99% assist with 2 people) and End of Goal Status as of 2/9/24 is *GOAL NOT MET - on 2/11/24 The patient is able to safely transfer from bed to wheelchair requiring Max A (assist) to Max A x 2; Goal for the patient to safely transition from sit to stand requiring moderate assistance x 2 (26-75% with 2 people) and End of Goal Status as of 2/9/24 is *GOAL NOT MET - on 2/11/24 The patient is able to safely transition from sit to stand requiring Max A to Max A x 2 to Mod A x 2 - Inconsistent; Long Term Goals documents Impact on Burden of Care/Daily Life: Complicating factors, including Decreased cognition prevent the patient from achieving all established goals; Precautions: Fall risk, cog impairments. Discharge Summary is signed off by V3 (Physical Therapist). On 5/25/24 at 12:13PM, V3 (Physical Therapist) was interviewed regarding R1. V3 stated, R1 is a long-term resident. In February she was a max x2 for transfers from the bed to wheelchair. When a person is in PT (physical therapy) we try to manually transfer them to help make them strong. If we need additional help, we get another staff. For safety of the staff and patient we told nursing after the rehab, once they get discharged (from physical therapy) we recommend they use a mechanical lift for transfers. We (PT) communicate during the care plan meetings, and we sit with the patient and the family and let them know. We (PT) work with CNA's as well so they know, and we tell them verbally. Max A means with assistance and Max A times two people, this is more than 75% effort is called Maximal. R1 can fluctuate between Max one and Max two and Mod assist two person, which is 50-75%. These are terminologies for therapy, which is different from nursing terminology. If there is a sudden or urgent change then we have the physician put the order in the EMR so that everyone sees it. Surveyor asked V3, being that R1 was discharged from PT on 2/9/24 and this incident occurred on 2/11/24, would the expectation be that at the time of the incident on 2/11/24, staff should have been using the mechanical lift to transfer R1 from the wheelchair to the bed and V3 said, yes. Review of R1's care plan documents the following interventions: - TRANSFER: (R1) requires Mechanical Lift with 2 staff assistance for transfers. Date Initiated: 5/20/24 - (R1) uses (mechanical) lift for transfer. Date Initiated: 5/20/24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145786 If continuation sheet Page 3 of 5 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 145786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincolnwood Place 7000 North McCormick Blvd. Lincolnwood, IL 60645 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 - Actual harm Residents Affected - Few It is noted that there are no interventions listed in R1's care plan regarding transfer status prior to 5/20/24. Surveyor asked for documentation of R1's care plan to show transfer status prior to care plan intervention dated 5/20/24 and it was not provided during the course of this survey. On 5/25/24 at 3:15PM V1 (Administrator), provided facility One Person Transfer Policy and confirmed that while it is for a one-person transfer, many of the steps are the same for two-person transfer. The Facility Policy One Person Transfer - Skilled Last Reviewed: 07/08/21, reads: Protocol: UNLESS OTHERWISE SPECIFIED BY STATE REGULATIONS Residents who have been evaluated/assessed as requiring one-person manual assistance will also utilize a Transfer belt and/or assistive devices to promote safety of resident and employee. See Transfer Belt Policy. Procedure: 1) Review Therapy evaluation, physician order and/or Resident Tasks in Point Click Care for assistance required. 2) Explain procedure to the resident and how he/she could assist and what devices will be used. 3) Never perform a Chicken Wing Transfer . The facility policy Activities of Daily Living (ADL), Supporting - Skilled Last Reviewed: 3/13/2023, which reads: Policy: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the assistance necessary to maintain good nutrition, grooming, and personal hygiene. Protocol: 1. Residents will be provided with the assistance and care necessary to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their medical condition(s) demonstrate that diminishing ADLs are unavoidable . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145786 If continuation sheet Page 4 of 5 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 145786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincolnwood Place 7000 North McCormick Blvd. Lincolnwood, IL 60645 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 c. Bowel and Bladder Elimination (toileting) . Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145786 If continuation sheet Page 5 of 5