Inspection·August 18, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few but close enough that I would be able to hear any alarm at the time. I was not aware about the alarm. The nurse who helped me said she has a bed alarm. The aide told me she was not sure if the alarm was on since V11 (Family Member) was still with her when she last saw her. V7 was also asked if R5 uses any type of assistive device to help with locomotion. V7 mentioned, She is alert, oriented to self and place. She is able to verbalize needs and wants but mostly confused during afternoon and night. She is ambulatory, she does not use any walker or wheelchair, I have not seen her using one.According to change of condition progress notes dated [DATE], R5 complained of moderate head pain.On [DATE] at 3:10 PM, V8 (Registered Nurse, RN) was interviewed regarding R5. V8 replied, She is confused, I helped V7 last [DATE] when she (R5) had the fall. I saw her (R5) walking in the hallway without any assistive devices. I told V7 that she (R5) was walking by herself. I wasn't sure if she is supposed to be walking or not, so I called her (V7) attention. I don't know if she (V7) heard me or not. She (V7) was at the nurses' station. After a while, they called me to help because she (R5) was on the floor. I came, she was laying on the floor, by the door of another resident's room. She (V7) did the assessment. At the time, I didn't hear any alarm gone off. I sometimes see R5 walking in the hallway by herself, with unsteady gait. I think she is supposed to have a bed/chair alarm.On [DATE] at 3:20 PM, V9 (CNA) was also asked regarding R5's fall incident on [DATE]. V9 verbalized, On [DATE], last time I checked on her, I put her to bed. I put two blankets on her per her request. She was sleeping in bed and bed alarm was on. When I came back from break, I was informed that she had a fall. She has bed and chair alarm. She uses wheelchair. She likes to walk but she needs to use a wheelchair.R5's medical professional progress notes dated [DATE], documented: Current functional status: wheelchairOn [DATE] at 11:21 AM, V2 (Director of Nursing) was asked regarding R5. V2 stated, She is able to ambulate but for safety we don't want her to ambulate alone. She has a wheelchair that she uses for locomotion. She did have a bed/chair alarm, nurses and CNAs are responsible to check for the functionality of the alarm. Staff must ensure fall interventions are in placed properly. If they see something that resident is doing that is not safe, they have to redirect residents and report any safety hazard, safety concerns. R5 can ambulate but unsteady with her feet so she needs assistance when ambulating, she needs to use her wheelchair. She is very confused all the time. She has unsteadied feet. That time she had a fall on [DATE], she (R5) was seen by V8 walking and tried to catch her not to fall. V9 was the CNA and was on break at the time.Progress notes dated [DATE] indicated R5 was admitted to the hospital due to skull fracture.R5's care plan regarding at risk for falls, dated [DATE] documented:Interventions:Encourage R5 to use her wheelchair when trying to ambulate around the unit to promote safety.Provide bed/chair alarm, and redirect R5 when seen restless or anxious. R1 is a [AGE] year-old, male, originally admitted in the facility on [DATE] with diagnoses of Malignant Neoplasm of Oropharynx, Unspecified; Malignant Neoplasm of Prostate; Secondary and Unspecified Malignant Neoplasm of Lymph Nodes of Head, Face and Neck; Polyneuropathy, Unspecified; Spinal Stenosis, Cervical Region and History of Falling. MDS dated [DATE] documented R1's BIMS score is 11, which means moderate impairment in cognition. R1 requires supervision or touching assistance during sit to stand; chair/bed to chair transfer; walking 10, 50 and 150 feet. He has no impairment on both upper and lower extremity but uses walker for locomotion. Fall incident report dated [DATE] recorded R1 was observed on the floor with left arm hanging on the left bedrail with head slouched over to the left side. An attempt was made to arouse R1 but did not verbally respond, only with eyes closed and opened. His level of consciousness was stuporous and only responsive to vigorous stimulation. On [DATE] at 12:25PM, V4 (CNA) was interviewed regarding R1 and R's fall on [DATE]. V4 replied, On [DATE], I went back to his room after giving morning shower to the other resident. He (R1) was sleeping. I went back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 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 in there after lunch, and he was on the floor on the left side of bed. He was sitting up on the floor. I asked him and he did not respond. He was still alert but not verbally responsive. I called the nurse. He was on a low air loss mattress; his left hand was in the rail.V5 (RN, Agency) was also interviewed regarding R1 on [DATE] at 12:52PM. V5 stated, On [DATE] morning shift, the CNA (V4) reported to me he was sitting on the floor. When I saw him, his arm was still holding the side rail. His head was slumped to the side of left side rail. I did head to toe assessment, he was not verbally talking, he can open his eyes a bit but not saying anything. He was sitting on the floor. I don't know if he slid down. He wouldn't keep his eyes open when I call his name. I called paramedics. He kept on grunting and kept closing his eyes. I noticed mild swelling on the left side of his face, by the eyes. There was no laceration, no issues with his eyes. He was not verbally responsive, his mental status is my focus, that is why I called emergency. I saw him on the floor and my first thing is to call paramedics because he was not responding.According to ambulance report dated [DATE], paramedics found patient (R1) lying in bed, alert to painful stimuli only. Nursing staff stated that they were in the room, left for about 5-10 minutes and when they came back, they found patient (R1) half on the floor with his arm wrapped around the side rail of bed. Staff stated the patient (R1) normally alert, oriented to self, time, place and situation and able to hold conversations. Patient (R1) was spitting up mucous and bruising was noted to the left side of his face and his left eye pupil was in a slit and rotated. No other injuries were noted.Emergency department attending physician notes dated [DATE] recorded R1 has bruising to the left side of head; and left eye is irregularly shaped, not circular, linear, not reactive.On [DATE] at 12:19 PM, V2 was asked on what was the cause of R1's fall. V2 verbalized, Based on what I received there was no injury related to the fall. He had a fall; he was observed on the floor by the CNA who reported to the nurse. And upon the nurse entering the room, she noted him not be responding. I did his fall investigation I have witness statements only, but there was no injury noted upon assessment prior to sending out to the hospital. The nurse said she did not know any swelling, nothing pretty much. Facility presented two witness statements related to R1's fall on [DATE], as follows:V5 was asked about representative notification; any bruising; hospital endorsement; last time R1 was seen and how long R1 was transferred to the hospital. V4 was asked when was the last time R1 was seen and his condition; and if she (V4) was the staff who observed R1 on the floor.There was no specific investigation related to the cause of his (R1) fall and how he fell. On [DATE] at 10:38 AM, V10 (Physician) was interviewed regarding R1 and R5. V10 stated, R5 has dementia, had traumatic subdural hematoma and has history of syncope and collapse. On [DATE], I was informed that she had a fall. She was sent to the hospital. R1 has multiple significant medical issues. Alert, he has cancer of the head and neck and was getting treatment from the hospital. He has cancer of the prostate, chronic kidney disease and multiple several medical issues: chronic or acute. He is getting blood thinners. On [DATE], I was notified that he had a change of condition, so he was sent out to the hospital, and he had a fall. The assumption was he had a fall, and he needs to go to emergency room. Staff should make all efforts to prevent falls. The goal is to prevent falls. Fall interventions should be patient centered. Facility's policy titled Fall Occurrence dated [DATE] stated in part but not limited to the following:Policy Statement: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Procedure:5. The Falls Coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall. Event ID: Facility ID: 145700 If continuation sheet Page 3 of 3