Health inspection·December 18, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few on. Then, after we removed the boots, I saw blood just before 911 came in. The nurses and everyone came to help but I could not stop the fall. The resident is a total assist and technically I was supposed to use two (person) assist but I was caring for him by myself. R1 had a low air loss mattressXXX[DATE] at 2:37 PM, V7 (Restorative Nurse/Fall coordinator) said, R1 had a fall from the bed and was sent out to the hospital. R1 was a total assist and required one assist. V7 did not provide any additional details regarding the fall. On review of the hospital record, R1 had a comminuted fracture of the left distal tibia. Dorsal displacement and angulation of distal fracture fragments. Fracture distal fibula with dorsal displacement major fracture fragment. V8 (Orthopedic Surgeon) notes indicated that operative versus nonoperative management was discussed with R1's brother and POA (power of attorney) wanted to proceed with surgery after risks and benefits were discussed, which included death, stroke, and myocardial infarction, to name a few risks mentioned by the surgeon. V9 (Critical Care Physician) notes indicated that R1 was taken to surgery and suffered a cardiac arrest upon induction. R1's code status was DNR (Do not Resuscitate) and in accordance with R1's wishes, no ACLS (Advanced Cardiovascular Life Support) was initiated and R1 expired at [DATE] 11:45 AM in a local hospitalXXX[DATE] at 2:49 PM, V2 (Director of Nursing) said, R1 had a bariatric air loss mattress and weighed 269 pounds, under hospice care, and was in and out of the facility, going back and forth to the hospital for being hypodermic or hypotensive. The interdisciplinary team met with the family and decided to go with hospice. During the fall, R1 was being cared for by one nurse assistant. R1 was having a bowel movement. R1 was not able to help or provide directions. R1 was not able to follow commands. The nursing assistant would call for help if they need assistance. V2 continued to say that a total/dependent resident with a ventilator, air loss mattress, who is incontinent only requires one person assist for care and that is what they always used for R1.Despite surveyor asking during interviews and review of documentation, there is no documentation supporting one-person assist during turning/incontinence care for R1.2. R2 admitted to the facility on [DATE] with the diagnoses including, Anxiety, heart failure, anemia, depression, hypertension, and dementia.Facility reportable documents that R2 was found lying on the floor on her back in the activity room on [DATE].Minimum Data Set (MDS) assessment of [DATE], Section C documents R2's BIMS (Brief Interview for Mental Status) score as 6/15, indicating severe cognitive impairment. MDS of [DATE], Section GG documents that R2 requires supervision or touching assistance. Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity. Assistance may be provided throughout the activity or intermittentlyXXX[DATE] at 11:20 AM, R2 said, I fell in the past but the last fall was bad. I was in the activity room and we had just finished making decorations for Christmas. I had my walker near me and just got up and started to walk when I saw a small box on the floor and I thought I could walk and tripped over it. The small box was on the floor because we were wrapping up and putting it away. I was by the Christmas tree. When I fell, I stayed there until 911 came to pick me up. I was taken to the hospital because I hurt my left eyebrow. I can walk around the facility and the staff will help me. R2 said that she did not call for assistance or wait to get assistance after the activitiesXXX[DATE] at 1:42 PM, V6 (Activities Aide) said, I was not present when R2 fell. I was bringing the other residents to their rooms after the end of the activities. The activity that the residents were doing that day was a craft and we were making a Christmas tree with felt. The Christmas bins with supplies were behind us and we were seated by the window; R2 was sitting next to me. R2 was with us for about 1-4 hours and there was no box on the floor near R2. On the other side, there was a Christmas tree with a small nativity under the tree and I did not see any box on the floor. The activity ended around 4:00 PMXXX[DATE] at 2:15 PM, V11 (Certified Nursing Assistant) said, I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145557 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 145557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was not there when R2 fell. I was passing by and I heard R2 had fallen and was already on the floor. Someone was already there with a paper over her forehead. I think the person was a visitor or a family member. I asked R2 how she was and R2 said she was okay. R2 was in the middle near the Christmas tree and there were little boxes of gifts as decorations under the tree. R2 walks around the facility with supervisionXXX[DATE] 2:49 PM, V2 (Director of Nursing) said, there should always be someone supervising residents during activities and when residents are going back to their rooms. I don't think we have an activity room policy/monitoring during and after activitiesXXX[DATE] 2:57 PM, V10 (Assistant Director of Nursing) said, R2 stood up without her walker and R2 said she kicked a small ornament, a square box, and lost her balance and fell. R2 had an unwitnessed fall just after finishing the activity. We had an activity aide in the kitchen and another was bringing residents to their rooms. When questioned about any activity room policy and monitoring during and after activities, V10 said that she didn't think there was any facility policy regarding activity room observation and monitoringXXX[DATE] at 12:24 PM V5 (Activity Aide) said, I was washing dishes in the activity kitchen next to the activity room after the activities and getting ready for dinner and my co-worker V6 (Activity Aide) stepped away from the activity when I heard a commotion and R2 was on the floor. R2 was sitting on her bottom near the Christmas tree and I did not see any box next to the tree and R2's walker was next to her. R2 can ambulate around the facility.Review of R2's hospital emergency room records and discharge notes document that R2 required three sutures to the forehead.Throughout the course of this survey, the facility was unable to provide a policy, procedure, or staff guidance regarding the supervision of residents in the activity room during or after activities for residents who are at high risk of falls.Facility Policy titled, Fall Management Program (revised on 08/2020), which reads: The facility is committed to minimizing residents' falls and or injury so as to maximize each resident's physical a psychosocial wellbeing. While preventing all residents' falls is not possible, it's the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls and plan for preventive strategies and facility a safe environment .4. Plan care reviewed and updated at the time of occurrence, quarterly, and as needed in order to minimize risks for fall incidents.Facility Policy titled Activity Calendar (revised on 11/16) reads: .4. The Activity Director or Designee will determine level of functioning through the assessment process and care plan this level per resident. The following information will be utilized to determine level of functioning: information from assessments, clinical observations, and the BIMS score from the MDS 3.0: 13-15: Cognitively intact, High Functioning, 8-12: Moderately impaired, Moderate Functioning, 0-7: Severely impaired, Low Functioning .10. Adaptations for residents will be determined based off the Comprehensive Activity/Memory Care Assessments and will be made on-going based off of the residents' needs. Event ID: Facility ID: 145557 If continuation sheet Page 3 of 3