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 provide adequate supervision on a resident who has
significant risk for falls for one of three residents (R3) reviewed for accidents.
Findings include:
During record review, R3's incident report dated 05/04/2025 with time of incident at 6:15PM indicated that a
resident from another wing alerted V7 (Licensed Practical Nurse) that R3 was sitting on the floor. It
indicated a CNA (Certified Nursing Assistant) was in the dining room with R3 sitting by the window and
watching on her phone. V7 asked V15 (CNA) what happened when V15 started yelling and screaming at V7
for no reason.
On 05/15/2025 at 1:12PM V2 (Director of Nursing) stated staff members should not be on their phones
when they are on the unit and when supervising residents in the common area to ensure adequate
supervision is provided to the residents.
Review of R3's CNA Post Fall Report dated 05/04/2025 indicated R3 was last visually seen at 5:30PM, last
toileted at 4:25PM, and given food and fluids at 5:30PM.
Review of R3's Fall Risk assessment dated [DATE] indicated R3 had a total score of 43 which indicates
significant risk for falls.
Review of R3's Fall Care Plan with problem onset date of 05/29/2022 indicated R3 a had a recent fall due
to decreased safety awareness most likely attributed to her dementia, impaired standing balance and
activity tolerance resulting in unsteadiness, hx (history) of multiple falls, presents with co-morbidities to
include DM (Diabetes Mellitus, TIA (Transient Ischemic Attack, dementia, hx of angioplasty with graft,
anemia, usage of psychotropic med (medication), BP meds, hypoglycemic agent, (+) with impulsivity, gets
up and walks abruptly without assistance, inconsistent with call lights, and approaches including to
anticipate toileting needs and offer toileting after dinner, offer to toilet after dinner with date 09/07/2023, and
offer to toilet after dinner with date 01/20/2023.
Review of V8's Compliments, Suggestions, and Concerns Form dated 05/05/2025 written by V4 (Director of
Social Services) indicated V8's concern on the care provided to R3 in the dining area on 05/04/2025. V15
was attending to her cellphone, and V15 was unaware of R3 sliding off the wheelchair.
Review of facility's policy entitled Fall Prevention last revised 07/2023 indicated the following:
(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:
145324
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
145324
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Park Ridge
1001 North Greenwood Avenue
Park Ridge, IL 60068
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Policy Statement: The intent of this policy is to provide an environment that is free from accident hazards,
over which there is control, and provide supervision and intervention to residents to prevent avoidable
accidents.
I. Fall Risk Evaluation - Residents shall be evaluated by the licensed nurse during the admission process,
routinely and as indicated; to identify potential risk for fall. If the resident scores a higher risk for falls, the
resident shall be placed on the Falling Star Program.
II. Fall Risk Intervention - The Interdisciplinary Team shall identify individualized interventions to reduce risk
of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the
associates may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at
once).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145324
If continuation sheet
Page 2 of 2
