Health inspection·December 13, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to adequately supervise a high fall risk resident for one of four residents (R26) reviewed for accidents in the sample of 14. Residents Affected - Few Findings include: On 12/10/2024 at 10:09AM during facility rounds, V15 (Certified Nursing Assistant) was observed coming out of R26's room and R26 was observed sitting on the toilet with R26's wheelchair in front of her with no staff present. On 12/10/2024 at 10:15AM during interview with V15, V15 stated that he went out of R26's room because he needs to grab another pair of gloves because what he had was the wrong size. V15 stated that he does not usually leave the resident but R26 is not a fall risk so he trusts R26 will not fall. On 12/12/2024 at 9:30AM during interview with V2 (Interim Director of Nursing), V2 stated that staff is expected to gather all their needed supplies before proceeding to resident's room and before starting to provide care to any resident. V2 stated that staff cannot leave any resident unattended until the task is completed. V2 also stated that if the resident wants some privacy, the staff can stay outside the bathroom with the door slightly opened to be able to hear or peek as needed. V2 stated that supervision means that one staff must be present to oversee and monitor the resident while performing the task. V2 stated that extensive assistance means that the resident cannot really do the task for themselves, so one or two staff must be present to provide support and assistance to the resident during care. Review of R26's Fall Risk Review dated 11/18/2024 indicated R26 has fall risk score of 13 which is considered a high risk for falls. Review of R26's Progress Notes dated 06/12/2024 indicated a fall incident was noted. Review of R26's Minimum Data Set (MDS) Section GG - Functional Abilities dated 11/18/2024 indicated R26 needs supervision or touching assistance with toileting hygiene, and partial/moderate assistance with toilet transfer. Review of R26's care plan revised on 11/22/2024 indicated that R26 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness d/t (due to) dx (diagnoses) of dementia, cerebral infarction, depression, adult failure to thrive. R26 is an extensive assistance of one staff member for toileting, bed mobility, transfer. (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 5 Event ID: 145786 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 12/13/2024 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)