Inspection·December 3, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement effective interventions to monitor a resident at high risk for falls. This failure affected one (R1) of three residents reviewed for falls and resulted in R1 sustaining a fall while in front of the nursing station for supervision, that resulted in emergent hospital transfer for treatment of a closed nondisplaced fracture of the acromial end of the left clavicle. Findings include: R1 is an [AGE] year-old female admitted to the facility on [DATE] with the diagnosis history of Congestive heart failure, hypoxemia, chronic obstructive pulmonary disease, dementia, cataract, gastric esophageal reflex disease, hyperlipidemia, and aphasia after cerebral infarct. On 10/15/2024 record review documents that R1 fell in front of the nursing station requiring R1 to go to the emergency room for further evaluation. Hospital records reviewed document that R1 had a closed nondisplaced fracture of the acromial end of the left clavicle and R1 was admitted to the hospital. On the (MDS) Minimal data Set assessment of 09/03/2024 section C the BIMS (Brief Interviewed Mental Status) score was 01/15 (severe cognitive impairment). On MDS of 09/03/2024 GG section R1 requires supervision/touching assistance with manual wheelchair mobility on 50 feet distance. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. On 12/02/2024 at 11:02AM interviewed R1 who was not able to answer questions, but only repeat the last words of each question such as pain for the question; Do you have pain? Did you have a fall? R1 answered fall. On 12/02/2024 at 11:25 AM V6 (Certified Nursing Assistant) said, R1 was assisted with her toileting needs after breakfast and brought to the nursing station for V5 (Registered Nurse) to monitor because R1 is a high fall risk. During the fall, V6 stated that she was in a room providing care to another resident. R1 can get anxious and not able to follow cues and redirections depending how R1's day is going. On 12/02/2024 at 12:44 AM V5 (Registered Nurse) said that she was standing at least 100 feet away (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: 145557 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 145557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010 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)