Inspection·November 27, 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 prevent an accident for a resident assessed to require two staff assistance with incontinence care. This failure affected one (R1) of three residents reviewed for falls and resulted in R1 experiencing a fall while being assisted with incontinence care by only one staff member. R1 required emergent hospital transfer for evaluation and sustained a left forehead hematoma, skin tear to right forearm, and left fifth metacarpal fracture. Findings include: R1 is an [AGE] year old female admitted to the facility on [DATE] with the diagnosis history of left Peri-prosthetic hip fracture, non-displaced fracture of 5th metacarpal of left hand, left subdural hematoma, COPD, left foot drop, osteoporosis, cataract, depression, hypertension, and Gastro-esophageal reflux disease. Per record review, on 09/28/2024 R1 rolled out of bed while receiving incontinence care requiring R1 to go to the emergency room for further evaluation. Hospital records documented that R1 had a hematoma to the left forehead, skin tear to right forearm and Xray results showed Left fifth metacarpal fracture. On 10/02/2024 R1 had a change of mental status and returned to the hospital. Hospital records reviewed with computerized tomography of the head showed a left 7mm subdural hematoma with 4mm midline shift as well as falcine and tentorial subdural hematoma. R1 was admitted to the NCCU (Neuroscience Critical Care Unit) for closer monitoring. On the (MDS) Minimal data Set assessment of 08/01/2024 section C the BIMS (Brief Interviewed Mental Status) score was 15/15. On MDS of 08/01/2024 GG section R1 is dependent with toileting and roll side to side. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On 11/25/24 at 10:44 AM R1 said that V7 (Certified Nursing assistant) was changing her brief and turned her towards the window and she rolled off the bed and hit her face on the oxygen concentrator. R1 said, It happened too fast, I fell face down, the staff helped me back to bed and the ambulance was here. The staff placed the mechanical lift pads under me and lifted me to bed. I still cannot understand what happened, and we did not do anything else differently. I went to the hospital and got all the testing done I got a fracture to my hip, left little finger and a big bump to my left side of my head. I was in the ER until 2:00AM before I came back to the facility. I returned to the hospital because I noticed that I did not make sense and I knew that something was not right. I ended up having a bleed in my brain, the hospital kept me for couple days and I came back. R1 said that she is not able to help with transfers and turn from side to side by herself and requires assistance. R1 (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: 145942 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 145942 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453 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)