Health inspection·September 14, 2023

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 observation, interview, and record review, the facility failed to follow safe transfer practices when utilizing a mechanical lift. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in a sample of 3. This failure resulted in R1 incurring 2 lacerations to her head requiring staples to both lacerations. Findings include: The admission Record documents R1 with diagnoses to include Parkinson's Disease, History of Falling and Muscle Weakness. R1's Minimum Data Set, dated [DATE], documents R1 as cognitively intact and requiring the extensive assistance of 2 staff for transfers. R1's Care Plan for Activities of Daily Living assistance, dated 7/27/2023, documents R1 to be transferred by 2 staff using a mechanical lift. A Progress Note, dated 8/30/2023 at 7:47 AM, documents R1 being transferred to the emergency room after the mechanical lift tipped over onto R1 during a transfer, causing right arm pain and lacerations to her scalp. At 10:38 AM, these notes document R1 returning from the emergency room with staples to her scalp lacerations. A signed statement completed by V3 (Agency Nursing Assistant) on 8/30/2023, documents V3 was transferring R1 from the bed to the wheelchair without assistance. During the transfer, R1 was yelling and grabbing the arm of the lift during the transfer, and as she was lowering R1 into the wheelchair, she was not aligned properly over her wheelchair, and the lift tipped over onto R1. On 9/13/2023 at 10:00 AM, R1 had 2 healing lacerations to her scalp, one above her left ear, and the second near the top of her head. R1 stated she was being transferred with a mechanical lift by one nursing assistant, and the machine fell over and striking her on the head causing the lacerations. On 9/13/2023 at 9:30 AM, V2 (Director of Nursing) stated V11 (Nurse) notified her of the incident, and arrived to R1's room to assist. V2 stated when she entered the room, the lift was tilted over on its side and R1 was partially in the wheelchair sideways, with her legs across the armrest of the (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: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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)