Health inspection·September 11, 2025

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 ensure effective supervision and monitoring of residents in the dining room to prevent accidents. Specifically, staff failed to maintain visual supervision of a resident assessed to be at risk for falls. This affected one of three residents (R1) reviewed for falls. This failure resulted in R1 sustaining an unwitnessed fall in the dining room and being sent to the local hospital where R1 was treated for a hip fracture. This past non-compliance occurred from 8-15-2025 to 8-29-2025. Findings include:R1's face sheet shows diagnoses including chronic hepatic failure hepatic encephalopathy anemia Alzheimer's type 2 diabetes COPD depression anxiety hypertension and dementia. MDS dated [DATE] section C shows Brief Interview for Mental Status (BIMS) score of 4 (cognitive impairment).The facility final report to the State department dated 8/22/25 denotes in-part R1 is a [AGE] year-old female resident who was admitted to the facility to 2/19/25 with diagnosis that include but not limited to chronic hepatic failure hepatic encephalopathy anemia Alzheimer's type 2 diabetes COPD depression anxiety hypertension and dementia. Resident is alert and oriented times one to two spheres and requires partial to moderate assist with ADL's (activities of daily living). BIMS 4/15. Resident was observed lying on the floor in the dining room with reports of pain resident alert and oriented times one to two per baseline. Hospice notified with orders to send to ER (emergency room) for further evaluation. POA (Power of Attorney) also notify of occurrence. Resident was transported to (hospital name) then subsequently transferred to (hospital name) where she was admitted with a right femoral neck fracture. It is probable residence led to floor based on proximity of wheelchair to table. Table mates were unable to provide detail regarding incident the nurse interview reveal the resident was seated at the table properly positioned with proper footwear a few minutes prior to the incident. During this investigation abuse was not found to be a factor based on staff/ resident interviews.On 9/3/25 at 2:05pm V5, Licensed Practical Nurse (LPN) said she was covering for R1's nurse because she was on break. V5 said she walked pass the dining room where she observed R1 sitting in her wheelchair at the second table to the left (front facing when walking through the doors of the dining room) R1's back was to the door. V5 said she did not see any food trays in the dining room, lunch was over. V5 said she went and sat down at the nurse station, across from the dining room. V5 said she could not see R1 from her position. V5 said she was monitoring the dining room from the Nurse station. V5 said a couple minutes later two staff members approached her an informed her that R1 was on the floor in the dining room, V5 said this was around 1:20pm, she looked at the clock. V5 said she did not see R1 fall. She did not see what R1 was doing just before she fell. V5 said she was not aware that R1 was at risk for falls, V5 said the Nurse did not give her a report before she took her break. V5 said she assessed R1, she observed R1 laying on the floor on her right side, she was laying in between two tables, her head was toward the wall and her feet was out. V5 said she palpated R1's body and when she touched R1 back, R1 winced and complained of Page 1 of 4 145963 145963 09/11/2025 Alden Estates of Orland Park 16450 South 97th Avenue Orland Park, IL 60467

F 0689 Level of Harm - Actual harm Residents Affected - Few pain. V5 said R1 did not have pain when she palpated R1's hip. V5 said R1 was not moved from the floor, and 911 was summoned, physician notified, and R1 daughter was notified. V5 said 911 took R1 to the hospital for further evaluation. V5 said there's no solid rule that someone must be in the dining room to monitor the residents, they can be monitored from the Nurse station. V5 said she did not see R1 fall, while she was monitoring the dining room.On 9/3/25 at 2:25pm V6 (Director of Nursing) said R1 had an unwitnessed fall. V6 said the root cause of R1 fall was maybe R1 was trying to take herself back to her room after lunch as she often did. V6 said V5 was monitoring the dining room when R1 fell. V6 said if the residents are in dining room staff should be there to monitor the residents. V6 said the staff should be able to see all the residents when monitoring the dining room. V6 said if she had to do things different, she would have the staff bring the residents out of the dining room after lunch. V6 said the residents can sit near the Nurse station for observation by staff.On 9/3/25 V2 (LPN) said R1 had to often be redirected and asked to sit down in her wheelchair because she could fall.9/3/25,12:46pm V4, Certified Nursing Assistant (CNA) said R1 had to often be redirected and asked to sit down in her wheelchair because she could fall.9/4/25 at 1:32pm V7 (CNA) said he was picking up lunch trays from the resident's rooms, as he headed to the dining room R1 was observed on the floor on her back. V7 said there were no other residents in there with R1. There were no staff in there with R1. V7 said he summoned the Assistant Director of Nursing and V5 (LPN). V7 said R1 was trying to get up a few times but she couldn't, V7 said he even went downstairs to get a lift pad just incase they was going to get R1 up. V7 said R1 often stood up from her chair and sat back down, and if the wheels were not locked the chair would roll backwards. V7 said he believes that what happened. V7 said V5 did assess R1, 911 was called and R1 was sent to the hospital for further evaluation.R1's care plan with initiated date of 2/19/25 denotes in-part R1 is at risk for falls related to weakness impaired mobility use of narcotic cognitive impairment diagnosis hepatic encephalopathy and Alzheimer's disease use of assistive device, use of medications that affects GI (gastrointestinal) motility, use of psychotropics overactive bladder continent of bowel and bladder. Goal: will remain free of falls through next review. Interventions: assure resident is wearing eyeglasses. Encourage appropriate use of Walker. Encourage appropriate use of wheelchair. Ensure that the bed is inappropriate lowest position for the patient and the bed is locked as appropriate. Fall risk assessment quarterly and as needed. Monitor for changes in ability to navigate the environment. Offer resident assistance to bathroom as needed throughout the night early morning when making rounds. Orientate resident to surroundings frequently including location of bathroom dining room bedroom and activity locations. Place resident in bed if returning her to her room period do not leave in room in wheelchair without supervision/monitoring. Promote placement of call light within reach. Provide an environment clear of clutter. Provide proper well-maintained footwear. Remove resident from common areas after completion of her meal.R1 fall risk assessment dated [DATE] denotes in-part post fall assessment, unsteady gait and or use of ambulatory device, confused, 1-2 falls in the last 3 months, taking medications that have a diuretic effect, drugs that affects thought process, and drugs that effect hypotensive effect, regularly incontinent: needs assist to et to the toilet. Score is 8, at risk for falls.R1 hospital record dated 8/15/25 denotes in-part Xray, hip, there is sclerosis the femoral neck, there is suspicious for an impacted nondisplaced right femoral neck fracture. Impression, probable nondisplaced femoral neck fracture.Facility policy titled Fall management program dated 8/2020 denotes in-part the facility is committed to minimizing resident falls and or injury so as to maximize each resident physical mental cycle social well-being. While preventing all resident falls is not possible it is the facility's policy to act in a proactive manner to identify and assess those residents at 145963 Page 2 of 4 145963 09/11/2025 Alden Estates of Orland Park 16450 South 97th Avenue Orland Park, IL 60467

F 0689 Level of Harm - Actual harm Residents Affected - Few risk for falls plan for preventive strategies and facilitate a safe environment.Prior to the survey date of 9/11/2025, the facility had taken the following action to correct the noncompliance:1. On 8/18/2025 the facility reviewed all residents that were a fall risk in the past 3 months and care plans were reviewed and interventions put in place.2. On 8/22/2025 thru 8/29/2025 the facility in-serviced all nursing staff on fall management program, fall prevention, and management of falls. Staff in-service on resident supervision while dining and after dining.3. On 8/18/2025 QA audit tool for dining room supervision developed and monitoring of resident started and continues to be done (8/18/2025 to 9/4/2025) audits reviewed.4. 8/29/2025 and emergency QA meeting was held by the Administrator with the interdisciplinary team and Medical Director and the team approved the past noncompliance plan. 145963 Page 3 of 4 145963 09/11/2025 Alden Estates of Orland Park 16450 South 97th Avenue Orland Park, IL 60467

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that the Infection Preventionist participated in the facility's QAA/QAPI programming. This failure has the potential to affect all 174 residents that reside within the facility. Findings include:On 9/09/25 at 1:49pm, V16 (Assistant Administrator) affirmed that V15 (Assistant Director of Nursing/ADON & Infection Preventionist) Became IP (Infection Preventionist) in February 2025.On 9/09/25 at 12:06pm, upon review of the Facility's Quality Assurance and Assessment (QAA) Committee meeting sign-in sheets dated 3/11/25, 4/08/25, 7/08/25, and 8/12/25 with V16 (Assistant Administrator), there was no documented signature from V15 (Assistant Director of Nursing and designated Infection Preventionist) to confirm her attendance. V16 (Assistant Administrator) confirmed that the facility's designated Infection Preventionist did not attend the Quality Assurance and Assessment (QAA) Committee meetings. V16 further acknowledged that, the Infection Preventionist is required to participate in QAA Committee meetings as a standing member. V16 confirmed that the intent of QAPI is to ensure that residents consistently receive safe, effective, and high-quality care that is subject to ongoing evaluation and continuous quality improvement.Facilities policy titled, QAPI Plan, revised date October 2019, documents, in part, . Leadership of our facility shall be ultimately responsible for the QAPI Program. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements.Facility job description titled, Infection Preventionist Nurse, dated 7/2024, documents, in part, . Participate in staff meetings, QA meetings.Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.Facility census, dated 9/08/2025, documents 174 residents residing at the facility. Residents Affected - Many 145963 Page 4 of 4