Health inspection·January 27, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few sit by the edge of the bed while I called another CNA for assistance. The R1 said she is dizzy and then she started sliding onto the floor. I held on to R1's gait belt and then she slid down on the floor. I informed V3, R1's nurse, that R1 refused to use the (mechanical) lift and V3 said that it's okay to transfer R1 with 2 person assist since she was refusing. When asked if V3 talked to R1 about dangers of not using the (mechanical) lift, V5 stated, V3 did not talk to R1 about it. V6, CNA, and V3 assisted R1 back to bed, with 3 person assist, we did not use the (mechanical) lift. On 1/26/2024 at 1:24 PM, R1 was interviewed again. R1 stated she did not refuse to use the (mechanical) lift and the (mechanical) lift was not offered for her to use. R1 stated, I have never used the (mechanical) lift. V5 did not have the Sit-to-Stand or (mechanical) Lift on 12/18/2023. We just didn't think to use it. I heard a crack on my bones when I fell on the floor. V5 and V6 assisted me to get up when I fell and put me back to the bed without using the (mechanical) lift. Progress Noted dated 12/18/2023 by V3, Registered Nurse documents in part: CNA (Certified Nursing Assistant) called NOD (Nurse on Duty) to informed (sic) that pt. (patient) slid to the floor during transfer (sic) resident to the wheelchair. NOD came to the resident room noted resident siting position on the floor next to the bed. Interview with V3, Registered Nurse, on 1/26/2023 at 1:20 pm was conducted. V3 stated, I was the nurse in charge of R1 on 12/18/2023. V5, Certified Nursing Assistant called me and informed me that R1 slid on the floor. V5 stated that she was getting R1 ready and had R1 sitting at the edge of the bed and R1 started slipping on the floor. I was then called to R1's room and observed R1 on the floor. I did a head-to-toe assessment, R1 said she was not in pain. V3 informed me then that (mechanical) lift was not used because R1 refused to sue the (mechanical) lift. When asked why her documentation on R1's progress notes stating that R1 refused to use the (mechanical) lift had a created date of 12/20/23, which was 2 days after the fall, V3 did not respond. R1's Care Plan with a revision date of 12/20/23 affirm that R1 requires (mechanical) lift with (X2) staff assistance for all transfers. The said Care Plan does not address that R1 was refusing to use the (mechanical) lift. On 1/26/2024 at 1:30 PM, V2, Director of Nursing stated, When somebody refuses the (mechanical) lift, the staff needs to inform us so we can do an evaluation to assess for proper transfer. R1 sustained fracture of the tibia. When I called V7, Physician, V7 said the fracture was pathological, we didn't report it. I talked to V7 the following day, he said it's due to her co-morbidities, R1 has severe osteopenia. If it's pathological in nature, we don't send a report to the state reporting agency. V2 affirmed that tibial fracture is considered a serious injury. V2 stated there was no report submitted to the state surveying agency about this serious injury. Review of R1's medical records excludes documentation regarding any condition that would place R1 at risk for pathological fractures. On 1/26/2024 at 1:55 PM, V7, Physician, stated, For R1, we discussed the fall, and the discussion was that R1 was sitting on the side of the bed and was being assisted and slipped and did not really have any per se trauma. We reviewed R1's X-ray and showed severe Osteopenia and that certainly can contribute to a pathological fracture, in the absence of trauma. R1's severe osteopenia could have caused the fracture because I was informed that there was really no trauma to the extremity. I have been informed from time to time that R1 was refusing to use the body lift, but for this particular incident, I don't recall them informing me that she refused to use the (mechanical) lift on 12/18/23. On 1/26/2024 at 3:12 PM, V6, Certified Nursing Assistant (CNA) stated, I was in the room with V5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. Northbrook, IL 60062 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 When I got there, R1 was already on the floor. V5 prepared R1 for the transfer, and V5 said R1 slid on the floor. Then nurse checked R1, and R1 said she has no pain. So, the nurse, V6 and myself (sic) put her back to the bed, all 3 of us without using the (mechanical) lift. R1 said she wanted to go to the beauty shop, so all 3 of us transferred her to the wheelchair this time without using the (mechanical) lift so that she can go to the beauty shop. Review of R1's medical records excludes any documentation that R1 was reassessed for proper transfer techniques since R1 was allegedly refusing to use the (mechanical) lift. Review of medical records also exclude documentation that R1 was educated on the dangers of refusing to use the (mechanical) lift. V3, Registered Nurse, affirm that she was informed that R1 refused to use the (mechanical) lift after R1 slid on the floor. V3 documented on the progress notes with a created date of 12/20/2023, which is 2 days after the incident, that R1 refused to use the (mechanical) lift. R1's hospital records document under Xray Ankle Complete Minimum 3 Views, (Right) and Xray Tibia/Fibula, 2 Views (Right): Final Result, IMPRESSION: A minimally displaced oblique fracture involving distal tibia is noted with nondisplaced distal fibular diaphyseal fracture. Facility Policy titled Safe Lifting and Movement of Residents with a review date of July 2022 documents in part: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. POLICY INTERPRETATION and IMPLEMENTATION: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 3 of 3