Health inspection·June 9, 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. Based on observation, interview and record review, the facility failed to maintain resident safety during a transfer utilizing the mechanical lift by failing to have two staff present during a transfer and failed to ensure the correct size mechanical lift sling is used during transfers as recommended by the manufacturer. This affected two of two residents (R2-R3) reviewed for safety and the mechanical lift. Findings Include: 1.) R2 alert and oriented with a BIMS score of 14 (Cognition Intact), Weigh 141.0 lbs. on 5/1/24. On 6/8/24 at 2PM, Mechanical lift transfer with 2 staff assistance was observed. V4 and V13 (CNAs) placed the Mechanical lift sling in bed behind R2. Mechanical lift sling is big in size and light bluish in color. V4 and V13 folded the bottom end to fit R2's body then hooked up and transferred R2 in wheelchair. V4 operated the machine and V14 assisted in guiding R2 in her wheelchair. R2 stated I have never seen a sling so big. Interviewed R2 and R2 stated that the sling they used today is bigger than R2 was used to. R2 then reported that sometimes they transfer me with the machine with only one staff present. V4 still in the room and confirmed that the sling that was used is big for R2. V4 stated that staff cannot find her small Mechanical lift sling pad. V4 also stated they probably washed it in the laundry, and we cannot find it. V4 stated that they usually used a small Mechanical lift sling pad for R2, which is blue in color. On 6/8/24 at 2:21PM, V13 (CNA) We cannot find Mechanical lift sling. Usually, we use the small one and this sling was big for her. V13 stated that today they don't have the right size for R2. Mechanical lift has to be 2 person assist, or more than two. But not less than 2. Our sling pad comes in blue or gray color. I think the one that we used for R2 was from the hospital. Too big for the patient. Maybe the one use for weights, maybe. We folded the bottom end of the sling pad because R2 needs to have her legs hanging. Usually, we don't have to fold it if the Mechanical lift sling is the right size for the resident. 2.) On 6/8/24 at 1:55PM, R3 is up in the wheelchair in her room, playing cards. Alert and oriented. When asked how many staff in assistance with Mechanical lift transfer, R3 stated at times one or two staff assistance. Today there was only one that transfer me using the machine. R3 has a BIMs score of 13 (cognition intact). Facility Mechanical lift transfer list provided by the facility. R2 and R3 are listed as transferring x 2 assist via Mechanical lift. Confirmed under task tab in residents' medical record and both shows that R2 and R3 are transferring via mechanical lift x 2 assistance. (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 2 Event ID: 145907 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 145907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Evanston 2520 Gross Point Road Evanston, IL 60201 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)