Health inspection·November 26, 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 ensure a resident was repositioned safely. This failure resulted in R1 sustaining a intertrochanteric (thigh/femur/hip bone) fracture that required an open reduction surgery. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 12. The findings include: On November 23, 2024 at 1:08 PM, R1 stated, V11 Certified Nursing Assistant (CNA) came to her room to change her multiple times. She refused to have V11 change her because she felt like she was rough with her. She refused to be changed two times. The third time, V11 CNA told her she was going to get changed and threw her legs over the rail and she heard a pop. After that she had pain in her left leg. She stated, she (V11) would not listen to nothing. Told her don't touch me and no, thank you. Now, I have to suffer for my hip fracture and have surgery. I might not be able to walk again. R1 started crying and gave the phone to her daughter (V3). R1's local hospital records dated November 21, 2024 shows, General: admission H&P (history and physical): History of present illness: R1 is a 60F ([AGE] year old female) w PMH (with a past medial history of) GERD (gastroesophageal reflux disease), OSA (obstructive sleep apnea), bipolar 1, HTN/HLD (hypertension/hyperlipidemia), asthma, hip replacement 8/17 with V14 c/b (complicated by) recurrent prosthestic left hip joint infection w recent discharge on 11/13, discharged on vancomycin and cefepime (both antibiotics), pw (patient with) left hip pain. She was at the facility receiving antibiotics and stated that one of the staff was too rough with me when changing my diaper and felt a pop in the area, reporting pain in the left hip . Assessment & Plan: .Stated she was handled roughly by staff and heard a pop in her joint. XR (x-ray): Left revision total hip arthoplasty with acute comminuted periprosthetic fracture of the left intertrochanteric region as described . On November 23, 2024 at 3:38 PM, R12 (R1's room mate) stated, she woke up to R1 having a problem with someone. R1 was upset because they hurt her while turning her. It had to do with her being moved in bed. Apparently whatever the CNA did added to her pain. R1 complained of pain the next day. Then she left to the hospital. I was under the impression she was in more pain than normally. On November 24, 2024 at 9:05 PM, V11 CNA stated, she worked November 19th on the night shift (into November 20th morning). That night she went to R1's room to change her and R1 stated no. She went back again and told her no again. The third time she tried to change her, R1 told her no, don't touch me. She denied ever changing her or touching her that night. R1's task list for November 19, 2024 shows, she was incontinent during the night shift. (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 11/26/2024 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)