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 stop providing ADL-Activity of Daily Living care
to prevent a fall when a resident exhibited known dementia related behaviors on a memory care unit for 1 of
5 residents (R1) reviewed for falls in the sample of 5.
This resulted in R1 fracturing her left hip and losing the ability to ambulate independently.
The findings include:
On 07/22/2024 at 11:50AM, R1 was lying in bed. R1 was calling out and complaining of pain.
R1's current Care Plan on 07/22/2024 shows, multiple diagnosis including Wandering Diseases, Dementia,
Behavioral Disturbance, Parkinson's, Anxiety Disorder, and Alzheimer's.
On 07/22/24 at 11:58AM, V7 RN-Registered Nurse said, R1 was in the wheelchair with family this morning.
R1 started crying, complaining of left hip pain, she then requested to go back to bed. R1 transfers with
extensive one person assists. R1 is using a wheelchair that the staff must propel. Prior to R1's fall she was
able to ambulate with a walker. R1 only needed verbal cues to remember to use her walker.
On 07/22/24 at 12:14PM, V5 CNA-Certified Nursing Assistant said, I provided R1 with a shower on the day
the resident fell. I put R1's shoes on. R1 became anxious and wanted to get out. R1 stood up as I was
trying to finish. The back part of R1's shoe was folded over. I tried to get R1 to sit down so I could fix it, she
wanted to leave. As I fixed the back of her shoe she stepped away and fell onto the floor. R1 did not have
her walker when she fell. After R1 fell, I pulled the call light for help. The other CNA and the Nurse helped
me.
On 07/22/2024 at 12:38PM, V4 R1's POA said, I do not know why they did not have her sit down before
messing with her shoe. That contributed to her fall. R1 was able to walk before the fall; she is not able to
walk now. Therapy says she has too much pain for rehabilitation.
On 07/22/24 at 2:46PM, V4 Restorative Nurse said, R1 is currently a two persons assist. R1 no longer
initiates movement on her own. R1 will not get out of bed independently which is what she did prior to her
falling. The new intervention to reduce the risk of falls for R1 is to ensure her shoes are on properly.
On 07/22/24 at 3:25PM, V6 R1's Primary Physician said, after the fall R1 was sent to the hospital.
(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:
146186
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
146186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden Estates Cts of Huntley
12140 Regency Parkway
Huntley, IL 60142
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)
F 0689
Imaging shows a femur fracture post fall. R1 received surgical intervention to repair the fracture.
Level of Harm - Actual harm
On 07/23/24 at 11:30AM, V2 DON-Director of Nursing said, it is an expectation the CNA's know the
resident's fall risk and precautions. R1 has a history of impulsive behavior. The CNA was adjusting R1's
footwear and R1 fell. R1 is a Memory Care Dementia resident. The CNA was familiar with resident. R1 was
independent. We have had conversations with V5 CNA and explained the need to have the resident sit
down to adjust shoes.
Residents Affected - Few
R1's Fall Risk assessment dated [DATE] shows, At Risk for falls.
R1's Care Plan shows, At risk for falls initiated 03/21/23. Encourage appropriate use of walker. Monitor for
changes in ability to navigate the environment. Provide proper, well-maintained footwear.
R1's Fall Investigation Report dated 06/11/2024 at 2:20PM, shows, Notes: dated 06/19/2024 shows, R1
has a history of Parkinson's disease, Alzheimer's disease, Anxiety, and Wandering disease. Resident is
impulsive. On 06/11/2024 at 2:20PM, nurse noted resident with clothes on, One Shoe Off, lying on her left
lateral side. New Intervention-CNA to ensure shoes on properly prior to resident walking.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146186
If continuation sheet
Page 2 of 2
