Health inspection·August 9, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident (R1) was assessed in a timely manner after being lowered to the ground during a mechanical lift transfer on 7/26/24 at 5:30 AM which resulted in a left hip fracture. The facility failed to notify the physician in a timely manner and provide ongoing nursing assessments from the time of the incident on 7/26/24 at 5:30 AM through 8/1/24 when R1 was transported to the emergency department for evaluation and treatment of a left hip fracture. These failures resulted in R1 not receiving required medical evaluations and treatment after being lowered to the ground when she was falling from a mechanical lift on 7/26/24. This applies to one of three residents (R1) reviewed for injury in the sample of three. Residents Affected - Few The findings include: The facility face sheet for R1 shows diagnoses to include fibromyalgia, Atrial Fibrillation, congestive heart failure and dementia. The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and required maximum staff assistance with bed mobility and transfers. The final report dated 7/31/24 for a bruise of unknown origin shows upon further investigation it was discovered that the resident was being transferred by a sit to stand lift for a shower. During the transfer, R1 became agitated and began to come out of the sit to stand sling. The report shows this staff lowered the resident to the floor. The sling caused pressure to the left shoulder which developed into a bruise. An additional follow-up, post 5-day summary dated 8/2/24 shows R1 was noted with bruising to her left lower extremity and had an increase in pain. An x-ray revealed a fracture to the left distal femur. The undated facility final conclusion for bruise and fracture of unknown origin, upon completion of investigation shows it is believed that the left femur fracture is related to the reported incident of resident being lowered to the ground by staff on 7/26/24. On 8/7/24 at 3:00 PM, V5 (Certified Nursing Assistant/CNA) said he was the CNA caring for R1 on Friday 7/26/24. V5 said he was to give R1 a shower that morning. V5 said the shower began around 5:30 AM. After the shower was completed and he was preparing to transfer R1, she became agitated and resistive to having the lift sling placed under her arms. V5 said he proceeded with the transfer anyway and as the transfer was happening, she began to slide out of the lift sling. V5 said her legs were standing on the base of the lift and she never fell to the floor. V5 said he was alone during the transfer and knows he was to have assistance with the transfer. V5 said he did not report the incident to the nurse because R1 did not get hurt and he didn't feel he had to. V5 said R1 was lowered to the ground and a sling for the mechanical lift was placed under R1 as she lay on the floor, and she was lifted up off the floor into her wheelchair. (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 5 Event ID: 146136 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 146136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Radford Green 960 Audubon Way Lincolnshire, IL 60069 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)