Inspection·May 4, 2023

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 fall interventions and provide adequate supervision to one resident (R1) out of four residents (R1, R2, R3, and R4) who were reviewed for falls. This failure resulted in R1 experiencing three falls in less than one month, and one of these falls resulting in a fractured right clavicle. R1 is a [AGE] year old male who was originally admitted to the facility on [DATE] and continues to reside in the facility. R1 has multiple diagnoses including, but not limited to the following: right femur fracture, muscle weakness, unsteadiness on feet, subdural hemorrhage, HTN (Hypertension), CHF (Congestive Heart Failure), CKD III (Chronic Kidney Disease stage 3), AFib (Atrial Fibrillation), gout, vascular dementia, right clavicle fracture, history of falling, depression, and CAD (Coronary Artery Disease). Facility incident report, dated 3/11/23 at 4:20AM, states in part but not limited to the following: CNA heard bed alarm and went to check on (R1). Noted patient lying on the floor on his left side by the footboard of the bed. Patient does not remember and states, I was dreaming that I was walking. Patient complains of slight pain to right shoulder. X-ray was ordered to right shoulder and urinalysis. Patient is alert and oriented x 1-2, forgetful and confused. New interventions: evaluate medications with MD and pharmacy input, neuropsychological evaluation, and check patient frequently. Facility care plan, with initiation date of 2/16/2023, states in part but not limited to the following: Focus: R1 is at risk for falls r/t generalized weakness secondary to right hip fracture status post ORIF (open reduction and internal fixation). Goal: Will remain free of falls through next review. Interventions: Ensure that the bed is in the appropriate lowest position for the patient and that the bed is locked as appropriate, dated initiated: 2/16/23; use of personal or pressure sensor alarms when in chair or bed, date initiated: 3/4/23; patient was reeducated on using his call light for assistance, date initiated: 3/4/23; evaluate medications with MD and pharmacy input, date initiated: 3/11/23; move resident to a room with optimal visual access from the nurses station, date initiated: 3/11/23, neuropsychological evaluation, date initiated: 3/11/23, check patient every 15 minutes, date initiated: 3/11/23; staff will do frequent checks on the patient, date initiated 3/11/23. On 05/04/23 at 11:20AM, V3 (Registered Nurse) was interviewed regarding R1. V3 said, (R3) is confused and he is a high fall risk. He needs increased supervision. (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 3 Event ID: 145869 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 145869 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Skokie 4626 Old Orchard Road Skokie, IL 60076 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)