Health inspection·December 6, 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 implement fall preventive measures for a resident who is a 2 person transfer assist due to limited mobility due to surgical site. This deficiency affects one (R1) of three residents reviewed for Falls prevention program. This failure resulted in R1 to have dislocation of the right hip prosthesis requiring hospitalization. Findings include:R1 is an [AGE] year-old with the following diagnosis: periprosthetic fracture around internal prosthetic right hip joint, history of falling, essential hypertension, hyperlipidemia, myelodysplastic syndrome, anemia, orthostatic hypotension, personal history of transient ischemic attack and cerebral infarction without residual deficits, age-related osteoporosis without current pathological fracture, polymyalgia rheumatica, presence of right artificial hip joint. Facility Reported Incident dated 11/24/25 documents during the transfer from toilet to wheelchair, R1 experienced sudden weakness in his right leg and was lowered to the floor by the CNA (Certified Nurse Aide). Head to toe assessment completed and the resident denied pain at the time of the fall. R1 reassessed for pain and stated he has pain in the right hip. MD and daughter were notified. X-ray was completed which revealed dislocation of the right hip prosthesis. R1 was sent to the emergency room for further evaluation. On 12/06/25 at 11:45 am, V2 (Director of Nursing) said that on 11/24/25 when incident occurred with transfer to toilet R1 should have been a 2-person transfer assist. V2 said that the certified nurse aide working with R1 during incident is no longer an employee at the facility for multiple reasons including resident safety. V2 said that R1 was transferred to hospital due to dislocation of right hip prosthesis and has not returned to facility. On 12/06/25 at 12:30 PM, V5 (Registered Nurse) stated that when incident with R1 occurred R1 was being transferred to the toilet by 1 staff assist (certified nurse aide). V5 said R1 is supposed to be a 2-person transfer assist due to R1 being a surgical patient and fall precautions needed to be in place. V5 said that the certified nurse aide called him to the room and V5 observed R1 in a sitting position on the floor. V5 assessed R1 with no change of Level of consciousness and no complaints of pain, V5 and the certified nurse aide assisted R1 back to bed using a gait belt. V5 said he notified the MD, family member and Director of Nursing. V5 said when R1 was reassessed for pain R1 said he was having pain to the right hip. V5 notified MD and received orders for x-rays of the right hip for R1 due to fall and complaint of pain. On 12/06/25 at 1:15pm, V6 (Restorative Nurse) said that R1 is a 2 person assist upon admission due to surgical site and having a wound vac, V6 said that she assessed the resident for transfer status assist upon admission and also refers to physical therapy for recommendation and if agreed then the transfer status is then updated in the residents chart and also in the resident point of care charting and updated in the transfer status binder located at the nurses station. On 12/06/25 at 2:00PM, V1 (Administrator) said that R1 had a fall in the facility and the fall was reported due to injury. V1 said that the certified nurse aide working with R1 during time of incident was suspended pending investigation and Page 1 of 3 145998 145998 12/06/2025 Alden Des Plaines Rehab & Hc 1221 East Golf Road Des Plaines, IL 60016

F 0689 Level of Harm - Actual harm Residents Affected - Few eventually was let go of the facility due to multiple factors. The Fall Risk assessment dated [DATE] documents At risk for falls. GG Screener assessment dated [DATE] documents Toileting Hygiene: Dependent transfer. Functional Abilities- admission assessment dated [DATE] documents Chair/bed to chair transfer: Dependent transfer. Toilet transfer: dependent transfer.Restorative Progress note dated 11/21/25 documents staff/patient education to use walker with 2-person assist to transfer using left side/good side for safety. Radiology Progress Note dated 11/25/25 documents Patient X-ray result was with hip dislocated.Physical Therapy Evaluation and Plan of Treatment dated 11/20/25 documents R1 is a Max assist out of bed and total dependence assist with transfers. The Care Plan dated 11/19/25 documents R1 is at high risk for falls d/t generalized muscle weakness, impaired mobility, gait, balance, decreased activity tolerance and medical diagnosis of right pre-prosthetic hip, myelodysplastic syndrome. Interventions in place include encourage appropriate use of walker, bed to chair transfer 2-person assist using rollator walker using good side/left side to transfer. The Care Plan dated 11/21/25 documents R1 has an ADL functional performance deficit due to generalized muscle weakness, impaired mobility, gait, balance, decreased activity tolerance and medical diagnosis of right pre-prosthetic hip, myelodysplastic syndrome. Interventions in place include bed to chair transfer 2-person assist using rollator walker using good side, left side to transfer. Facility Policy on Transfer revision date 2/10/2022Definition: Transfer refers to activities provided to improve or maintain the resident's self-performance in moving between surfaces or planes either with or without assistive devices. These activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record. Considerations:2. Fractures- Follow physician orders regarding movement or weight bearing restrictions and any therapy recommendations when developing individualized programs. General transfer guidelines:1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe transfers of residents. 2. Manual lifting of resident's should be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include:a. Resident's preferences for assistance. b. Resident's mobility (degree of dependency)c. Residents sized. Weight-bearing abilitye. Cognitive statusf. Whether the resident is usually cooperative with staff g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. General Transfer Procedures:3. utilize assistive devices as needed: bedrails, walker, slide board, etc.7. transfer toward the resident stronger side and place the chair/wheelchair at the resident's stronger side when possible. Facility Policy on Management of Falls revision date 8/2020Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the residents plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure:1. Complete a Fall Risk Assessment upon admission, re-admission, with significant change, post-fall, quarterly, and annually. 3.Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following contributing diagnosis/disorders/diseases processes/ active infections/ other comorbidities, history of fall incidents, incontinence, medications (Narcotics, Antihypertensives, etc.), assistance required with ADL's, gait/transfer/balance issues, Behaviors, and /or cognitive status. 4. provide assistive devices for mobility, hearing and vision as appropriate for the resident. 5. Assess appropriateness for resident to participate in skilled therapy or 145998 Page 2 of 3 145998 12/06/2025 Alden Des Plaines Rehab & Hc 1221 East Golf Road Des Plaines, IL 60016

F 0689 restorative programming in order to maintain or improve physical function or resident. Level of Harm - Actual harm Residents Affected - Few 145998 Page 3 of 3