Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
interviews and record review, the facility failed to follow its policy and properly transfer a resident with a
mechanical lift device during a transfer procedure for one (R1) resident out of three residents reviewed for
resident safety. This failure resulted in R1 sustaining a fracture of the right knee while being transferred in
the facility.
Findings include:
Face sheet dated 09/12/2024, documents R1 is an [AGE] year-old female with diagnoses not limited to:
Osteitis deformans, chronic embolism and thrombosis, hypothyroidism, hyperlipidemia, chronic kidney
disease, hypertension, and vitamin D deficiency.
R1's MDS (Minimum Data Set) dated 08/20/2024, documents R1 has a BIMS (Brief Interview for Mental
Status) of 04/15 indicating R1 is severely cognitively impaired. R1's Activities of Daily Living (ADL)
Assistance documents R1 is dependent with ADL care. R1 is dependent with transferring from bed to chair.
R1's MDS documents walking activity for R1 did not occur. The activity of walking 10 feet was also not
attempted for R1 due to R1's medical condition or safety concerns.
On 09/12/2024 at 10:02AM, R1 observed sitting in the second floor dining room fully dressed and sitting in
a Geri chair. R1 stated she fell while walking in the facility when she was in the basement. R1 stated she
did not sustain any injuries. R1 noted with confusion during interview.
On 09/12/2024 at 10:18AM, V2 (Director of Nursing) stated R1 did not experience a fall in the facility. V2
stated R1 was improperly transferred with a mechanical lift device by a CNA staff member (identified as
V4/CNA). V2 stated V4 was a new staff member who was recently hired at the facility. V2 stated she was
informed by the nurse (V3/LPN) R1 was reporting right knee pain, so the facility ordered an x-ray of R1's
knee the same day. V2 stated R1's x-ray report documented R1 had a right knee fracture. V2 stated she
then reported to the state agency R1 had an injury of unknown origin. V2 stated she then started an
investigation and found out during her investigation V4 transferred R1 with a mechanical lift device alone
without any assistance from other staff. V2 stated R1 requires the use of a mechanical lift device to be
transferred and this requires two person assistance. V2 stated V4 terminated her own employment by not
coming back to the facility after providing V2 with a statement. V4 no longer works at the facility.
On 09/12/2024 at 10:39am V3 (Licensed Practical Nurse/LPN) stated she was assigned to work on the
second floor of the facility and assigned to care for R1 on 08/13/2024. V3 stated she was made aware by
the CNA (identified as V5/CNA) R1 was complaining of knee pain. V3 stated she went to R1's room
(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 3
Event ID:
145977
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
145977
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
South Shore Rehabilitation
2425 East 71st Street
Chicago, IL 60649
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
and performed an assessment and R1's right knee was swollen. V3 stated she contacted R1's nurse
practitioner/NP and made R1's NP aware of R1's knee status. V3 stated R1's NP was located inside of the
facility during time and assessed R1 in person and ordered an x-ray to be performed on R1. V3 stated the
x-ray company performed an X-ray on R1 the same day. V3 stated she administered pain medication to R1
while awaiting the ordered x-ray. V3 stated she asked R1 what happened but R1 was unable to give an
account of what happened to R1's knee. V3 stated R1 is often confused. V3 stated she was made aware by
R1's NP R1's x-ray report showed R1 had a fracture. V3 stated R1's NP order a knee brace for R1's right
knee and ordered orthopedic appointments for follow up care. V3 stated she carried out the NP orders. V3
stated she contacted R1's POA/power of attorney and made her aware of R1's knee status. V3 stated R1's
NP also gave orders to send R1 out to the ER to be evaluated. V3 stated R1's POA stated she did not want
R1 to go to the ER but just wanted R1 to wait for her follow up appointment with the orthopedic.
On 09/12/2024 at 11:23AM, V2 (DON) stated during her investigation, V2 spoke with V4 (CNA) via
telephone to inquire about R1's knee. V2 stated V4 informed her V4 transferred R1 to a Geri chair without
any assistance by pivoting R1's body into the chair. V2 stated she asked V4 the reason for pivoting R1
without assistance during transfer when R1 requires the use of a mechanical lift device with two person
assistance. V2 stated V4 said V4 was aware R1 required the use of a mechanical lift device for transfers. V2
stated she made V4 aware she needed V4 to come into the facility to speak with V2. V2 stated V4 agreed to
come into the facility but never came back into the facility to speak with her. V2 stated she still has not
heard from V4 since then. V2 stated she believes the pressure from V4 pivoting R1 is what caused R1's
right knee fracture. V2 stated R1's resident care card is kept in R1's room and visible for staff to see.
An attempt to contact V4 (Certified Nursing Assistant/CNA) was made on 09/12/2024 at 12:05PM, unable
to leave voicemail due to voice mail being full.
On 09/12/2024 at 12:11PM, V5 (CNA) stated she was the CNA responsible for caring for R1 on
08/13/2024. V5 stated while she was performing rounds, R1 groaned and told V5 R1 was in pain. V5 stated
she asked R1 where her pain was located and R1 took her right hand and pointed to R1's right leg. V5
stated she then went to get the nurse (identified as V3/LPN) and informed V3 R1 was complaining of pain.
V5 stated V3 immediately followed V5 back to R1's room. V5 stated she observed V3 questioning R1 about
what happened and observed V3 assessing R1. V5 stated she heard R1 tell V3 R1 was in pain. V5 stated
she then left R1's room and resumed caring for her other assigned residents. V5 stated she later received a
phone call from V2 (DON) inquiring about R1's knee and what happened during the time V5 was caring for
R1. V5 stated she informed V2 she was not aware of what happened with R1's knee and only reported to
V3 (LPN) what R1 had reported to V5. V5 stated R1 requires a two person assist when being transferred
with a mechanical lift device. V5 stated the protocol for using the mechanical lift device is to always call
another staff member to help transfer a resident who requires a mechanical lift device. V5 stated if a staff
member operates the mechanical lift device without the assistance from another staff member while
transferring a resident, the mechanical lift device can tilt over, and the resident could fall and injure
themselves. V5 stated while operating the mechanical lift device, one staff member should be located at the
back of the mechanical lift device and one person should be located in the front of the mechanical lift
device. V5 stated this procedure helps to prevent resident injuries.
On 09/12/2024 at 3:05PM, V6 (Staff Coordinator) stated she was made aware R1 was injured due to a
transfer in the facility. V6 stated she was asked by V2 (DON) to contact V4 (CNA) via telephone to ask V4 to
come into the facility to give a statement. V6 stated V4 told her V4 could not come to the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145977
If continuation sheet
Page 2 of 3
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
145977
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
South Shore Rehabilitation
2425 East 71st Street
Chicago, IL 60649
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
facility because V4 was informed V4 was taken off of the schedule and was under investigation because V4
transferred R1 alone without any staff assistance. V6 stated she then asked V4 if V4 transferred R1
improperly and V4 stated yes. V6 stated she continuously tried to text and call V4 for several days after the
initial phone call but V4 never answered V6's calls or texts afterwards. V6 stated V4 never returned to the
facility to follow up on V4's employment at the facility either.
Nursing progress note dated 08/12/2024 at 3:35PM written by V3 (LPN) documents, Writer was called into
R1's room, writer noted R1's right knee with swelling and pain. PRN pain medication given and tolerated.
NP/Nurse practitioner is in the facility, new orders for X-ray of the right given. All orders noted and carried
out.
Nursing progress note dated 08/13/2024 at 10:29AM written by V3 (LPN) documents, X-ray company is in
the facility to perform X-ray on R1's right knee. NP is also in the facility to assess R1.
Nursing progress note dated 08/13/2024 at 3:29PM written by V3 (LPN) documents, X-ray results were
relayed to NP, new orders were given to send R1 out to ER. Family was made aware of orders, POA/Power
of Attorney stated she does not want R1 to go out to the emergency room, she does not want R1 to have to
be sitting and waiting for long periods of time and they won't do anything. She stated she wants R1 to wait
on her Dr. appointment. R1 has an outpatient Ortho appointment on 8-21-24 @8am. NP is aware of family
wishes.
Per facility reported incident dated 08/13/2024, R1 sustained a right knee fracture while at the facility.
Facility witness statement dated 08/14/2024 written by V2 (DON) documents V4 informed V2 V4 transferred
R1 from the bed to the chair without the use of the required mechanical lift devices.
R1's X-ray report dated 08/13/2024 documents R1 has an acute fracture of the mid patella with 1cm
separation of fracture fragments.
Facility nursing schedule dated 08/10/2024 documents V4 (CNA) was assigned to the 2nd floor during the
10PM-6AM shift.
Facility CNA assignment sheet dated 08/10/2024 documents V4 (CNA) was assigned to care for R1.
R1's resident care card documents R1 requires the use of a mechanical lift device with two person
assistance.
R1's care plan dated 06/07/2022 documents in part, R1 requires assist with ADL'S related to Impaired
Mobility. Transfer from bed to w/c and vice versa with use of Hoyer Lift x 2 staff.
Facility policy undated, titled, Safe Lifting and Movement of Residents documents in part, Policy Statement:
In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility
uses mechanical lifting devices for the lifting and movement of residents. 1. Mechanical lifting devices shall
be used for any resident needing a two person assist. Except during an emergency situation or unavoidable
circumstances, manual lifting is not permitted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145977
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the September 13, 2024 survey of SOUTH SHORE REHABILITATION?
This was a inspection survey of SOUTH SHORE REHABILITATION on September 13, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SOUTH SHORE REHABILITATION on September 13, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.