Inspection·May 17, 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 Based on interviews and record reviews, the facility failed to provide effective supervision to prevent an avoidable fall for one resident (R1) exhibiting increased confusion/agitation/wandering due to dementia. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 being involved in a fall incident sustaining a right femur fracture. Findings include: R1's medical record notes R1 with diagnoses including, but not limited to, diabetes, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, and weakness. R1's MDS (minimum data set), dated 3/14/24, notes R1's BIMS (brief interview of mental status) score was 5 out of 15. R1 required partial assistance with bed mobility. R1 required substantial assistance with toileting, transfers, and bathing. Per CMS (Centers for Medicare and Medicaid Services) a BIMS score 0-7 notes severe cognitive impairment. R1's care plan, initiated 3/8/24, notes R1 is at risk for falls related to gangrene left toes, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, weakness, and reduced mobility. R1's physical therapy evaluation, dated 3/8/24, notes R1 presents with balance deficits, body awareness deficits, decreased static/dynamic balance, and strength impairments. On 5/15/24 at 2:05 PM, V5 (Rehabilitation Director) stated R1 was receiving physical therapy from 3/8/24 4/9/24. V5 stated R1 was able to walk with a front wheeled walker and contact guard assistance. V5 stated R1 was not able to walk without a walker. V5 stated R1 needed verbal cues for hand placement on walker with ambulation. On 5/15/24 at 2:30 PM, V4 CNA (certified nurse aide) stated V4 was working on the other wing of the nursing unit. V4 stated V4 went onto the wing R1 resides on and was looking for the lift device. V4 stated V4 observed the lift device halfway down the hall near R1's room and retrieved it. V4 stated V4 heard something as he was pushing the lift device near the nurses' station. V4 stated when he looked back, he saw R1 on the floor by a resident's door. V4 stated he was not sure if was R1's room or not. V4 stated he was not paying attention to the surroundings prior to R1's fall. V4 denied seeing a walker near R1. On 5/15/24 at 2:45 PM, V3 RN (registered nurse) stated on 4/10 about 8:00 PM, V3 heard a commotion and saw V4 CNA with R1. V3 stated R1 was laying on the floor halfway in another resident's room and (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: 145982 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 05/17/2024 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)