Health inspection·June 13, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate adaptive equipment during transfer of a resident which resulted with the resident falling and sustaining a bruise and an abrasion on the resident's knees. This failure affected 1 (R1) resident reviewed for use of adaptive equipment in the total sample of 5 residents. Findings include: R1's (06/05/2024) Fall documented, in part Staff notified nurse that the resident is on the floor in the shower room. Immediate Action Taken. Description: Body assessment done(,) noted with small superficial abrasion to left knee, no bleeding and small bruise to right knee. Notes. 6/6/2024. (R1) is dependent on transfer with (mechanical lift). (R1) has history of falling. On 6/5/2024, CNA (certified nursing assistant). was going to give a shower to the resident, resident was standing up holding on to the side rails in the shower room and going to transfer to the shower chair, resident(')s legs gave in and was assisted to the floor by the CNA. Head to toe assessment, noted with small abrasion to left knee and a small bruise to right knee. Intervention: (Mechanical lift) to be utilized for all transfer. On 06/12/2024 at 11:10am, with V5 (Licensed Practice Nurse/LPN) R1 was noted with a quarter size reddish purplish discoloration on the right knee and about a penny size scabbing on the left knee. R1 stated I (R1) fell. On 06/12/2024 at 2:14pm, with V12 (CNA), R1 stated there was no sling on the wheelchair. There was no sling on my chair on that day because (V17 CNA), put me on the wheelchair without using the mechanical lift. I (R1) was by the nurse's station close to the dining room around 3:00pm and the CNA (V11) took me (R1) to the shower room. I (R1) was about to sit on the shower chair, and I (R1) fell. On 06/12/2024 at 2:17pm inside the 3rd floor's shower room with V12, R1 stated the CNA (V11) told me (R1) to hold on to the grab bar, she (V11) pulled me up while she (V11) was behind me, she (V11) took the wheelchair off me (R1) and I (R1) fell. On 06/12/2024 at 1:10pm, V4 (Registered Nurse) stated it happened during the morning shift, after lunch. She (R1) was seated by the nurses station on the wheelchair and I (V4) told the CNA (V11) that she (R1) needed a shower. I (V4) was with another resident when (V6 -LPN) told me (V4) that (R1) fell in the shower. When I (V4) got to the shower room, the CNA (V11) was leaning against the wall and (R1) was seated on (V11)'s lap. There was no mechanical lift sling on the floor and on the shower chair. I (V4) think she (V11) transferred (R1) from the wheelchair to the shower chair without using (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: 145888 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 145888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Northmoor 5831 North Northwest Highway Chicago, IL 60631 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)