Inspection·January 11, 2024

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 observations, interviews and record reviews, the facility failed to supervise a resident that ingested another resident's medication. This failure resulted in R1 being hospitalized for drug overdose, fast heartbeat, and altered mental status. This applies to one out of seven residents (R1) reviewed for supervision with medication. The findings include: On 1/9/2024 at 12:50 PM, V4 (ADON-Assistant Director of Nursing) said an incident occurred between the hours of 4:30 AM to 5:00 AM. He said V19 (RN-Registered Nurse) received a delivery from pharmacy on 12/17/2023 at 1:13 AM. Soon after delivery, V19 left the medication on top of V20's (RN) medication cart which was inside a locked unit. V19 did not inform V20 of the delivery. Around 4:30 AM, V21 (CNA-Certified Nurse Assistant) saw R1 walking around the unit and holding a bingo card of medication (Chlorpromazine 25 mg (Milligrams), 30 tablets). The medication she was holding was for another resident. V21 noticed that 18 tablets were popped. V21 found 8 tablets on the floor. Ten tablets were not found. R1 was noted to have a whitish substance on her mouth. R1 was brought to her room and was assessed. R1's heart rate was 116 beats per minute. R1 became lethargic and she was sent to a local hospital where admitting diagnoses were drug overdose, tachycardia and altered mental status. R1's admission Records showed her original admit date was on 11/10/2022. R1 was discharged to a local hospital on [DATE] and was readmitted on [DATE]. Diagnoses include accidental poisoning by unspecified drugs, medications and biological substances and dementia. R1's MDS (Minimum Data Sheet) dated 11/10/2023 documented R1's cognition as moderately impaired and needed supervision or touching assistance with ambulation. R1's MDS dated [DATE] documented R1's cognition as severely impaired and needed supervision or touching assistance with ambulation. On 1/9/2024 at 10:12 AM, V7 (RN) said the incident could have been avoided if the medications were secured and if staff were aware that R1 was walking around the unit at that time. On 1/9/2024 at 12:19 PM, V17 (NP-Nurse Practitioner) said R1 accidentally ingested unknown amounts of Chlorpromazine 25 mg and became lethargic that is why she was sent to a local hospital for further evaluation. She said Chlorpromazine is very sedating and caused R1 to be lethargic. She said if medications were properly stored and if staff saw R1 walking around, the incident would not have happened. On 1/9/2024 at 12:30 PM, V4 (ADON) said R1 would not have accidentally ingested 10 tablets of (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 3 Event ID: 145329 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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)