Health inspection·December 5, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review the facility failed to ensure staff safely transferred a resident by not using a gait belt for 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's Face Sheet printed on 12/5/24 showed R1 was a [AGE] year-old female that was diagnosed with abnormalities of gait and mobility, muscle weakness, and history of falls. R1's fall Care Plan with an initiated date of 10/18/24 showed R1 was at risk for falls related to generalized weakness, activity intolerance, severe protein-calorie malnutrition, spinal stenosis, history of falls, and needing assistance with activities of daily living. The facility's Incidents report with a date range of 9/5/24- 12/5/24 showed R1 had a fall on 11/3/24, 11/12/24, and 11/17/24. R1's Progress Note dated 11/17/24 showed a Certified Nursing Assistant (CNA) was walking R1 to the bathroom and R1 lost her balance and fell. The CNA attempted to lower R1 to the ground, but a gait belt was not in use. On 12/5/24 at 11:45 AM, V7 (Restorative Nurse) said she was involved with R1's fall on 11/17/24. V7 said V11(CNA) was assisting R1 to the bathroom when R1 fell. V7 said she went to assess R1. V7 said she found R1 on the floor near the foot of R1's bed. V7 said R1 did not have a gait belt on. V7 said staff should have used a gait belt when assisting R1 to walk. V7 added that a gait belt is used to help stabilize a resident when walking and possibly be used to lower a resident to the ground if needed. On 12/5/24 at 12:52 PM, V11 said on 11/17/24 R1's call light was on. V11 said she entered R1's room and found R1 sitting on the side of the bed wanting to go to the bathroom. V11 said she helped R1 to stand. According to V11, R1 was walking to the bathroom when R1's right leg gave out causing R1 to lose her balance and fell to the ground landing on her right side. V11 said she tried to ease R1 to the ground but R1 did not have a gait belt on. V11 said R1 was a resident that required a gait belt. On 12/524 at 10:13 AM, V10 (Therapy Director) said R1 required assistance from staff to walk and staff should have used a gait belt when assisting R1 to walk. Page 1 of 2 146008 146008 12/05/2024 Alden of Waterford 2021 Randi Drive Aurora, IL 60505

F 0689 A facility assessment dated [DATE] showed R1 required supervision or touch assistance with ambulating. Level of Harm - Minimal harm or potential for actual harm The facility's Gait Belt/Transfer Belt policy dated 9/2020 showed a gait belt will be used with weight bearing residents who require hands on assistance. Residents Affected - Few 146008 Page 2 of 2