Health inspection·March 7, 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. Based on observation, interview and record review the facility failed to ensure resident environment remains free of accidental hazards and the environment is free of sharp objects that could harm the residents. This failure affected R5 and R18 who has sharps stored on their bed side table and has the potential to affect all 31 residents residing on the 4th floor of the facility. Findings include: On 02/28/24 at 11:45, in R5's room on the bedside table observed 23 disposable shaving razor sticks, 1 pair of scissors and two nail clippers. At 11:46am, V12 LPN (Licensed Practical Nurse) restorative nurse who stated that she is the medication nurse and in charge of the floor was made aware of the observation and shown the 23 disposable shaving razor sticks, 1 pair of scissors and two nail clippers. V12 counted the razora with the surveyor and stated it's 23, I'm not sure why (R5) would have this many razors. V12 counted and stated five (5) of the razors were used and they should be thrown away in the dirty utility room in the sharp container and the clean shaving razors are kept in the clean utility room, the CNAs' (Certified Nurse's Aides) closet. No sharps are to be kept in the residents' rooms. At 11:47am, 1 razor and 1 pair of scissors was observed on R18's bed side table. R18 stated I (R18) keep it there so I can use it whenever I want to. At 4:03pm, V4 ADON (Assistant Director of Nurse's) stated the facility policy & protocol on sharps is that razors are kept in the nurse's station or kept in the supply room, used ones should be disposed /thrown away in the sharp's disposable bin. The facility Safety /Hazard surveillance policy with effective date February 2014 documented that the policy purpose is to promote an environment for residents, staff and visitors that is free from safety hazards and assure all facility areas in compliance with local and state regulations. The facility Sharp Objects Policy with effective date February 2014 documented in part that the policy is to assure that sharp objects are properly contained, promoting a safe environment. Listed policy specification includes but not limited to placing any sharp objects in a sharp container. 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: 145482 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 145482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660 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)