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 that fall interventions were in place for a resident
with a history of falls. This failure affected one (R4) of four residents reviewed for falls and resulted in R4
experiencing an unwitnessed fall which resulted in a nasal fracture.
Findings include:
R4 was admitted to the facility on [DATE] with diagnoses that included: Left humerus fracture (status post
fall), dementia, weakness, and lack of coordination. On admission, Minimum Data Set assessment dated
[DATE] documents that R4 has severe cognitive impairment and according to notes, was non-verbal, and
hard of hearing.
Fall incident reports were reviewed relating to R4 experiencing three unwitnessed falls in the facility on
8/26/24, 9/9/24, and 10/10/24.
8/26/24 incident report notes at 12:40 pm a nurse on duty heard a noise and rushed to the dining room. R4
was found on the floor in the dining room laying on R4's back and left side. The nurse notes that just five
minutes prior, R4 was assisted with eating lunch. R4 was sent to the hospital for evaluation related to the
incident. Interventions updated in the care plan after the fall included Will prevent fall by adding the use of
bed alarm and wheelchair alarm to resident fall prevention plan. R4 was admitted to the hospital for
evaluation and treated for a urinary tract infection. R4 returned to the facility 9/2/24. The Order Summary
Report included an order written 9/3/24: Bed alarm and wheelchair alarm for fall risk patient.
On 10/23/24 at 12:26 PM, V7 ADON (Assistant Director of Nursing) said that when a resident is at a risk, or
has had multiple falls, the interdisciplinary team meets and discusses the root cause of the fall and updates
the care plan right away. The interventions are implemented as soon as the care plan is updated. Once the
intervention is implemented, it should either auto-populate or can be added to the CNA (Certified Nursing
Assistant) tasks. This ensures proper monitoring and ensuring the chair and bed alarms are functioning and
being used appropriately.
Fall incident of 9/9/24 occurred at 7:30 pm and was described as follows: (R4) was seated at the nursing
station in wheelchair prior to fall. (R4) was observed on the floor, smiling upon the writer's arrival. (R4)
unable to give description. Interventions after this fall included evaluating seating system for modifications
as needed and evaluate multiple falls to determine commonalities or patterns.
(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:
145998
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
145998
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden Des Plaines Rehab & Hc
1221 East Golf Road
Des Plaines, IL 60016
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)
F 0689
Level of Harm - Actual harm
Fall incident of 9/10/24 occurred at 2:15 am and Nursing Description includes: 'at 2:15am R4 noted at the
door in front of room face down, nosebleed noted. R4 was conscious but confused.' Nursing progress notes
relating to this incident, note that R4 was sent to the hospital via 911 and was diagnosed with a nasal
fracture. R4 returned to the facility after evaluation in the afternoon on the same day.
Residents Affected - Few
On 10/23/24 at 10:23 AM, V8 Registered Nurse (Agency) said after arriving to the facility, V8 did rounds at
about 1:00AM and saw R4 in the bed. V8 remembers specifically viewing R4, because V8 received in
report that R4 had fallen earlier in the day. V8 said there were chairs near R4's room, however V8 did not
see any nursing assistants on the unit, and furthermore V8 was answering call lights due to no nursing
assistants being available. Shortly after 2:00am, V8 described sitting at the nurse's station on the computer
and seeing a flash from the corner of the eye. V8 got up to investigate and found that R4 appeared to have
gotten up from the bed and ambulated several feet across the hall before falling in the doorway. V8 called
out for help and staff came to assist. V8 said there was no unusual sounds or alarms heard at the time.
On 10/22/24 at 3:06 pm, V9 CNA (Certified Nursing Assistant) said they were working the overnight shift at
the time R4 fell however, V9 was on break at the time. V9 said R4 was in bed prior to leaving for break, and
informed another CNA of leaving the unit, however V9 said that they did not inform the nurse. V9 said
another CNA (V10) came to assist after hearing V8 call out, and V10 texted V9 to return to the floor. V9
could not remember if R4 had a bed alarm activated, or on the bed when rounds were performed prior to
leaving the unit.
R4's care plan was updated 9/4/24 to duplicate the use of pressure alarms while in chair and bed, however
after reviewing the Point of Care documentation (CNA tasks), staff did not begin documenting use of
pressure alarms until the morning (7am-3pm) shift 9/10/24.
Facility Policy Management of Falls revised 8/20 states in part; Policy: The facility will assess hazards and
risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions,
and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the
resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145998
If continuation sheet
Page 2 of 2
