Health inspection·January 24, 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 observation, interview and record review the facility failed to ensure a mechanical lift (Hoyer) was used to safely transfer a resident to bed for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 being sent to the hospital with a laceration to her right posterior thigh that required 9 stitches after being transferred with a sit to stand lift. The findings include: R1's Face Sheet shows that she was admitted to the facility on [DATE] with diagnoses of end stage renal disease, lack of coordination, hypotension, dependence on renal dialysis, anemia, abnormalities of gait, abnormal posture and bradycardia. R1's Minimum Data Set assessment dated [DATE] shows that R1 requires substantial/maximal assistance to roll from left to right and is dependent on staff to move from sitting to lying, lying to sitting on side of bed, sit to stand and chair/bed to chair transfers. On 1/24/24 at 10:17 AM, R1 was laying in bed. R1 had a bandage to her right mid-posterior thigh. R1's Facility Incident Report dated 1/20/24 shows, On 1/16/24 around 5:00 PM patient was being transferred from the wheelchair to the bed with the sit to stand machine, her right knee buckle and she slid down during transfer. The patient did not make contact with the floor. Patient slid down by the bed where she was laid back down. When asked what happened, the patient stated that her legs became weak suddenly. Bleeding was noted on her pants, on the posterior right thigh skin tear was noted on the posterior right thigh ordered to send patient to ER (Emergency Room) for further evaluation and treatment. Patient returned to the facility within couple of hours with stitches present on right posterior thigh. R1's After Visit Summary from the local hospital dated 1/16/24 shows a diagnosis of: laceration of right lower extremity. R1's Wound Assessment Details Report dated 1/17/24 shows R1 has a wound on the right posterior thigh measuring 9 centimeters (cm) x 7 cm x 0.2 cm with 9 stitches present. R1's Change in Condition Form dated 1/16/24 shows, the patient had a skin tear during the sit to stand transfer machine, the patient was sent out due to skin tear needing stitches, before ambulance transferred patient to ER, PRN (as needed) pain medication was administered . (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 2 Event ID: 145923 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 145923 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr North Shore 2773 Skokie Valley Road Highland Park, IL 60035 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)