Inspection·December 15, 2022

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 implement resident specific fall prevention interventions for a resident with severe cognitive impairment for 1 (R6) of 5 residents reviewed for falls in the sample of 42. This failure resulted in R6 being transferred to the hospital's emergency department where he was diagnosed with a hip fracture and had subsequent hip surgery. Findings include: R6 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Unspecified Asthma, Hypertension, Alzheimer's Disease, Major Depressive Disorder, and Dementia. According to MDS (Minimum Data Set) dated 05/18/2022 under section C, R6 has BIMS (Brief Interview of Mental Status) score of 4 indicating severely impaired cognition. According to MDS (Minimum Data Set) dated 05/18/2022 under section G, all shows R6's functional status for transfers requires extensive assistance with one-person staff assist to transfer, walk in the room, and toilet use. Fall risk assessment dated [DATE] shows R6's fall risk evaluation score of 12, indicating very high risk for falls. On 12/12/22 at 01:17 PM Surveyor observed R6 in his room. Bed placed against the wall, fall mat present on the right side of the bed. Bed in the lowest position with upper side rails up. Call light within R6's reach. R6's speech unintelligible, surveyor unable to conduct interview. On 12/14/22 at 11:51 AM Surveyor interviewed V16 (Registered Nurse/ fall preventionist), V16 stated, One of the reasons why R6 suffered multiple falls withing this year (2022) is that R6 has gait imbalances and is very impulsive. R6 is often displaying unpredictable behaviors, like trying to remove his clothes while being assisted to the bathroom. R6 was evaluated for urinary tract infections several times; however, all came back with negative result. V16 stated, When R6 was on the initial unit, he was placed right across from the nursing station. Additionally, R6 was encouraged to participate in day-care program to keep him occupied with multiple activities throughout the day. V19 (Psychiatrist) and the family were also involved in R6's care. Evenings and nights appeared to be the culprit of R6's fall problem. R6 had 12 fall incidents from the beginning of 2022. The hip fracture was suffered during one of his episodes of impulsiveness on 06/14/2022. R6 was attempting to get up without assistance. V17 (Certified Nursing Assistant) just rounded on R6 and offered toileting; around (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 6 Event ID: 145667 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 145667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Park Ridge 1601 North Western Avenue Park Ridge, IL 60068 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)