Health inspection·May 29, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to provide the fall prevention interventions for cognitively impaired residents who are also at risk for falls. This failure has the potential to affect 5 residents, R3, R4, R5, R6, and R7 out of 7 reviewed for proper footwear as a fall prevention intervention. Findings include: On 5/27/25 at 11:20am during observation of residents in the second-floor dining room, the following were observed: R3 was observed sitting in the wheelchair in the day room with white socks that are smooth on the bottom. R4 was observed sitting in the wheelchair in the day room with other residents with grey/white socks that are smooth on the bottom. R5 was observed sitting in the wheelchair in the day room with other residents with grey/white socks that are smooth on the bottom. R6 was observed sitting in the wheelchair in the day room with other residents with dark grey socks that are smooth on the bottom. R7 was observed sitting in the wheelchair in the day room with other residents with black socks that are smooth on the bottom. Again on 5/27/25 at 11:45 AM, all 5 residents still had the same socks on. At this time, V6(CNA/Certified Nurse Assistant) was notified. V6 stated We will get the non-skid socks for them. The non-skid socks are needed to prevent falling. On 5/27/25 at 12:10pm, V7(Restorative Nurse) stated All residents need to wear nonskid socks so keep them from falling. I will make sure. Please, can you give me the names of the residents? On 5/27/25 at 12:15pm, V8 (Unit Manager) stated I am the unit manager; they told me that some residents don't have the nonskid socks. We have some in the storage and we will make sure that the residents wear the socks. Page 1 of 3 145983 145983 05/29/2025 Aliya on 87th 2940 West 87th Street Chicago, IL 60652

F 0689 Level of Harm - Minimal harm or potential for actual harm On 5/27/25 at 2:15 PM, V2(Director of Nursing) stated I have in-serviced all of them. I don't know why they did not put the non-skid socks on for the residents because we have them in the storage. At this time, V2 presented the facility document titled Maintaining Proper Footwear. This document dated 5/27/25 states All residents must have skid proof footwear on at all times when out of bed to increase safety and comfort. No exceptions. Please notify management with any questions or concerns. Residents Affected - Some R3's records reviewed are as follows: Fall Risk assessment dated [DATE] states that R3 is at high risk for falls. Face sheet show diagnoses which include but are not limited to Dementia, Generalized Anxiety Disorder, Major Depressive Disorder, and Altered Mental Status. Care plan dated 12/31/24 states in part that R3 is at risk for falls due impaired cognition. Basic Interview for Mental Status (BIMS) Score dated 5/2/25 could not be assessed due to Severe Cognitive Impairment. R4's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Dementia, Major Depressive Disorder, Altered Mental Status, Unsteadiness on Feet, And Generalized Muscle Weakness. Fall Risk assessment dated [DATE] states that R4 is at high risk for falls. Care plan dated 2/27/24 states in part that R4 is at risk for falls due to history of repeated falls, unsteady gait, decreased safety awareness, confusion due to dementia, incontinence and lower extremity muscle weakness. BIMS Score dated 5/27/25 is 4 out of 15(Severe Cognitive Impairment). R5's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Dementia, Major Depressive Disorder, Slurred Speech, Gait Abnormality, And Generalized Muscle Weakness. Fall Risk assessment dated [DATE] states that R5 is at high risk for falls. Care plan dated 5/26/25 states in part that R5 is at risk for falls due to history of repeated falls, unsteady gait, decreased safety awareness, confusion due to dementia, incontinence and lower extremity muscle weakness. BIMS Score dated 5/6/25 is 6 out of 15(Severe Cognitive Impairment). R6's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Dementia, Major Depressive Disorder, Abnormal Posture, Aphasia, Lack of Coordination, Hemiplegia and Hemiparesis, And Cerebral Infarction. 145983 Page 2 of 3 145983 05/29/2025 Aliya on 87th 2940 West 87th Street Chicago, IL 60652

F 0689 Fall Risk assessment dated [DATE] states that R6 is at high risk for falls. Level of Harm - Minimal harm or potential for actual harm Care plan dated 1/9/23 states in part that R6 is at risk for falls. BIMS Score dated 5/1/25 could not be assessed due to Severe Cognitive Impairment. Residents Affected - Some R7's records reviewed are as follows: Face Sheet Shows Diagnoses Which Include but Are Not Limited to Dementia, Difficulty Walking, Alzheimer's Disease, and Generalized Muscle Weakness. Fall Risk assessment dated [DATE] states that R7 is at high risk for falls. Care plan dated 10/28/24 states in part that R7 is at risk for falls due to history of falls, unsteady gait, decreased safety awareness, confusion due to dementia, incontinence and lower extremity muscle weakness. BIMS Score dated 5/6/25 is 6 out of 15(Severe Cognitive Impairment). Facility's Fall Prevention and Management Program with latest review date 2/2025 states in part: While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. #2: Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk. #4: Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence. 145983 Page 3 of 3