Health inspection·August 12, 2023

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 observation, interview, and record review the facility failed to supervise a resident at high risk for falls for 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in R1 sustaining a fractured left hip from a fall. The findings include: R1's admission record shows he was admitted to the facility on [DATE] and re-admitted [DATE] following a hospital stay from 7/9/23 to 7/13/23. The same document shows R1 to have multiple diagnoses including dementia, history of falling, and difficulty in walking. R1's care plan initiated on 3/25/23 documents he is a high risk for falls related to weakness and being non-compliant with using his walker during ambulation. R1's quarterly resident assessment and care screening of 7/4/23 shows he has severe cognitive impairment. The same assessment documents he requires extensive assist of one person for transfers between surfaces, walking in his room, and walking in the corridor. The facility's final incident report of 7/13/23 shows R1 was in the dining room for activities, attempted to transfer himself, lost balance, and slid to the floor in a supine position (face up). The report shows R1 sustained a left hip fracture. R1's nursing progress note of 7/9/23 documents at 2:35 PM, R1 was on the floor of the dining room, resident complaining of pain in back of his head, noted bump on back of head, left leg pain, no swelling, no change in ROM (range of motion), MD notified, and order for transfer resident to hospital. On 7/10/23, the notes show R1 was admitted to the hospital with a diagnosis of fall with left hip fracture. On 8/12/23 at 9:15 AM, V4 (Activity Aide) said he was working on 7/9/23, and R1 was present in the dining room. V4 said V5 (Certified Nursing Assistant/CNA) was assigned as the monitor and was to watch over the residents. V4 said while conducting activities he had witnessed R1 standing up from his wheelchair, caught him, and placed him back in his chair. V4 said he did not see R1 when he fell. V4 said R1 was a fall risk, and that is why he was in the group. On 8/12/23 at 9:40 AM, V5 (CNA) said she was in the dining room on 7/9/23, assisting another resident with bingo. She said R1 was in the dining room in his wheelchair, he had no pedals on the chair, and his was not able to propel himself. V5 said she was in the corner of the dining room, and was (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: 145999 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 145999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Niles 6601 West Touhy Avenue Niles, IL 60714 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)