Health inspection·November 9, 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 observation, interview, and record review, the facility failed to ensure fall prevention measures were in place for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 5. The findings include: R1's electronic face sheet printed on 11/9/24 showed R1 has diagnoses including but not limited to fracture of 2nd lumbar vertebrae, cerebral infarction, bipolar disorder, schizophrenia, and hypertension. R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment and requires substantial assistance for transfers. R1's care plan dated 12/28/18 showed, (R1) is at high risk for falls related to impaired mobility, history of cerebrovascular accident, history of falls, and psychotropic drug use .requires use of floor mat to prevent injury from falls, place call light within reach, use wheelchair for locomotion and mobility and ensure device is operable. On 11/9/24 at 10:28AM, R1 was in his bed with his wheelchair and over the bed table next to his bed. R1's floor mat was folded up and leaning against the wall by his door. R1's wheelchair had both wheels locked; however, surveyor was able to move the wheelchair around due to the right brake not locking completely. On 11/9/24 at 11:05AM, V3 (Registered Nurse) stated, (R1) should have his call light within reach and a fall mat next to his bed at all times. He just had a fall with a fracture in his vertebrae, so we need to ensure we have all precautions in place for him. He is noncompliant at times asking for help, so we at least need to make sure everything is in place. Surveyor then accompanied V3 to R1's room where she visualized and confirmed that R1's floor mat was not in place and then attempted to activate R1's call light and it was not lighting up to alert staff if he needed assistance. On 11/9/24 at 1:50PM, V2 (Regional Nurse Consultant) stated, Fall prevention measures should be in place for all residents that have a care plan for these items. The measures are implemented to prevent injury and hopefully prevent falls. If (R1) does not have a working call light, he cannot call for help. If his fall mat is not in place, then he could potentially be injured during a fall. We were not aware that (R1's) wheelchair was not locking all the way. This potentially could have contributed to his last fall, but we cannot be sure as (R1) does not really recall his most recent fall. (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: 146058 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 146058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Evanston 1300 Oak Avenue Evanston, IL 60201 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)