Inspection·May 26, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, and record reviews, the facility failed to put fall risk interventions in place for 5 residents, (R1 - R5) who are at high risk for falls in a sample of 5. Residents Affected - Some Findings include: On 5/24/23 between 11:35am and 3:33pm, and 5/25/23 between 11:49am and 2:37pm, tours of the facility were conducted and R1 - R5's name plates and wheelchairs did not have indicators on them, identifying them as being fall risks. On 5/26/23 at 8:37am, R1 was observed in his bed with his call light on the floor out of his reach. On 5/24/23 at 3:30pm and on 5/26/23 at 8:49pm R2 was observed in his bed with his bed in a high position. On 5/24/23 between 11:45am and 11:50am, R2 and R3 were observed in the dining room in their wheelchairs with only socks on their feet that were not non-slip/non-skid socks. On 5/25/23 at 11:49am, R3 was in her wheelchair, and she did not have a non-slip pad under the cushion of her wheelchair. On 5/26/23 at 8:44am, R3 was in her room sitting in her wheelchair and her non-slip device was not under the cushion of her wheelchair. R1's 5/18/23 Care Plan showed that R1 is at risk for falls with falls on 5/18/2023 and 5/23/2023. R1's interventions included keep at nurse's station for close supervision. R1's 5/22/23 Fall Risk Evaluation showed R1's score of 17. The fall risk evaluation showed scores above 10 are high risks for falls. R2's 5/27/21 Care Plan showed R2 was a risk for fall with injuries and the care plan showed that on 4/16/22 R2 slipped out of the bed and on 9/25/22 R2 slipped out of the shower chair. R2 care plan showed interventions including anticipate needs, use of appropriate well-fitting footwear, call light within reach, and provide heavier shower chair. R2's 3/9/23, admission Fall Risk Assessment showed a score of 11. The assessment showed that any score above 10 is at high risk for falls. R2's 5/25/23 Physicians Order Sheets showed that R2 is on the blood thinner Clopidogrel 75mg daily. R3's 7/28/19 Care Plan showed that R3 is at risk for falls related to impaired cognition impaired mobility and possible side effects of medication. R3's care plan showed falls on 1/12/22, 3/3/22, 6/5/22, 7/30/22, 3/15/23, and 4/29/23. R3's interventions included non-skid device under wheelchair cushion and use appropriate well-fitting footwear. R3's 3/16/23 Quarterly Fall Risk Assessment showed a score of 13. The assessment showed any score 10 or above is a high risk for falls. R3's 5/25/23, Physician Order Sheets showed that R3 is on the blood thinner Eliquis 5mg daily. R4's 3/10/20 Care Plan showed R4 is at risk for falls related to a history of falls. R4's care plan (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: 146170 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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)