Inspection·November 12, 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 that bathroom toilet handlebars and sink were properly installed to prevent from falling on a resident. This failure applied to one (R1) of three residents reviewed for accidents. Findings include: R1 is [AGE] years of age and current diagnoses include but are not limited to: Heart Disease with Heart Failure, Anemia. R1's MDS (Minimum Data Set) dated 09/12/2024 documented his BIMS (Brief Interview for Mental Status) score of 15 which indicates he is cognitively intact. R1 was not interviewed because he was discharged to another facility. On 11/04/2024 at 12:24PM, surveyor interviewed V8 CNA (Certified Nursing Assistant) about the fall incident that R1 sustained on 09/15/2024. V8 stated, I have worked here for about 6 six years, it will be six years in January. On the night of the incident, I heard a call light go off. I checked my hallway and there were no lights on there. So, I checked the other hallway and I saw R1's light on. I went to check his room. The nurse was in there already. I observed him on the bathroom floor, laying on his stomach. He said the sink fell on him. He was not observed by the sink. The call light was by the toilet. His legs were by the toilet, and his upper part of the body was in the room. We asked him how the sink fell on him, and he stated he was trying to pull up his pants and that the sink fell on him. His pants were observed to be pulled up and buckled and belted. He said he was in pain, so we did not try to get him up. Ambulance was called. On 11/04/2024 at 2:15PM, surveyor interviewed V4 (Building Manager) about the repairs that needed to be made in R1's bathroom after the fall incident that R1 sustained. V4 stated, I was informed on Monday morning about the broken sink in the room. I went to the bathroom. The sink was on the floor, the toilet rails were broken off. So, I closed the bathroom immediately and called local plumbing company to fix and they got here immediately. They replaced the wall and attached the sink. It took a few hours to fix. No work had been done in that bathroom since I started working here. No other incidences have occurred in the facility since I started working here in December. I put in a new faucet on that sink around February. The sink was stable. V4 provided a picture of the bathroom with the broken toilet bars and the sink on the floor. V4 also provided the work order for the repairs that were done on 09/16/2024. (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 4 Event ID: 145173 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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)