Inspection·November 22, 2023

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 follow their policy to transfer a resident according to the resident's care plan. This applies to 1 of 3 residents reviewed for improper nursing care in the sample of 5. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, heart failure, dementia, anxiety, and falls. R1 was discharged from the facility on November 11, 2023. R1's MDS (Minimum Data Set) dated August 10, 2023, showed R1 had severe cognitive impairment. R1 required extensive assistance from two facility staff for transfers between surfaces. R1's ADL (Activity of Daily Living) care plan dated September 28, 2019, showed, [R1] requires extensive to total assist with ADL, non-ambulatory requiring total staff assist with transfers with [mechanical lift]. Has diagnosis of Parkinson's and dementia receiving hospice care. Potential for ROM (Range of Motion) decline due to immobility and use of [high back wheelchair]. Multiple interventions dated November 19, 2020, including, Transfer: [mechanical lift], extensive assistance, two plus persons physical assist. The care plan continued to show an intervention dated August 11, 2022, [Mechanical lift] for transfers. On November 20, 2023, at 1:03 PM, V3 (CNA/Certified Nursing Assistant) said V3 cared for R1 on November 4 and November 5, 2023. V3 said he transferred R1 multiple times during those shifts and each time he transferred R1 by himself and did not use the mechanical lift. V3 said V3 put his arms under R1's armpits and picked R1 up and pivoted R1 to the bed or the wheelchair. V3 said V3 knew R1 required a mechanical lift for transfer, but since R1 was so small V3 did a manual transfer by himself without the mechanical lift. On November 20, 2023, at 1:45 PM, V5 (CNA) said V5 cared for R1 on November 3, 2023. V5 said when V5 transferred R1 he used the mechanical lift by himself. V5 said V5 transferred R1 by himself because R1 was having a good day and V5 thought it would be safe to transfer R1 by himself. V5 said facility staff are always supposed to transfer residents with a mechanical lift with two staff members. On November 20, 2023, at 4:21 PM, V2 (DON/Director of Nursing) said V3 and V5 should have transferred R1 using the mechanical lift with two facility staff members present. (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 11/22/2023 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)