Inspection·April 11, 2024

F 0689 asked regarding the importance of supervising residents who are high risk for falls V13 stated, It is important for the resident safety, but we cannot supervise all the time. Level of Harm - Actual harm Residents Affected - Few On 04/10/24 at 10:50 am, V21 (R3's Physician) stated that R3 is a resident who has some levels of dementia and confusion. V21 stated that R3 is a resident who has had frequent falls at the facility and that V21 is not surprised that R3 has not had more falls at the facility. V21 stated that V21 recalls R3 falling on 03/20/24 and V21 gave orders to send R3 to the local hospital for evaluation. V21 explained that R3 received one stitch due to R3's fall at the facility on 03/20/24. V21 stated in V21's professional opinion, it is safer for R3 to have staff supervise R3 to prevent R3 from an injury. On 04/10/24 at 12:58 pm, V2 (Director of Nursing, DON) stated that R3 is a resident that is alert to self, difficult to understand and has difficulty communicating needs. V2 explained that R3 ambulates with a wheelchair, is a high risk for falls, requires supervision and assistance from staff for transfers and R3's care. V2 stated that on 03/20/24 staff reported responding to R3's call light and observed R3 sitting on the floor in R3's room. V2 explained staff did not know how long R3's call device was alarming. V2 then explained that V13 (RN, R3's nurse at the time of R3's fall), assessed R3 on the floor, R3 was observed with a laceration to R3's right eyebrow. V2 explained that V13 called V21 (R3's Physician) who gave orders to send R3 out for an evaluation. V2 stated that R3 was transferred to the local hospital and returned with one suture to R3's right eyebrow. When V2 was asked in V2's professional opinion if a resident is high risk for falls and requires assistance from staff for transfers and care; should they be supervised? V2 stated, Yes. When V2 was asked if a resident who is high risk for falls, sustains a fall, could the resident sustain an injury, V2 stated, In most cases, yes. V2 also stated that nurses and CNAs should be supervising the residents, answering call lights promptly and rounding every hour to check on the residents at the facility. The facility's document dated 12/08/24 through 04/08/24 and titled All Falls For the Facility shows that in the past 120 days, R3 sustained a fall on 03/20/24, 02/13/24 and 01/24/24. R3's progress note dated 03/20/24 at 3:51 pm, authored by V13 (Registered Nurse, RN) documents in part, CNA responded to call light and noted R3 in a sitting position on her floor mat. V13 was called to the room and observed R3 had a small amount of blood to the right side of R3's face . physician notified with orders to send R3 to the local hospital. R3's progress note dated 03/20/24 at 10:39 pm, authored by V13 (Registered Nurse, RN) documents in part, resident back to the facility via ambulance from local hospital with one suture to the laceration to right eyebrow. Sutures to be removed in seven days. R3's care plan dated 03/14/24 documents in part: Problem: R3 is high risk for falling due to unsteady gait, impaired mobility, uses wheelchair for locomotion. Approach: Educate never to transfer without staff assistance . observe frequently and place in supervised area when out of bed. R3's hospital records dated 03/20/24 documents in part that R3 was sent to the emergency room from skilled nursing facility after mechanical fall where R3 struck her head . Irrigated and sutured by physician assistant (PA) at the local hospital. Assessment/Plan: Head injury, Laceration of face (right eyebrow), right hip pain, and left hip pain. R3's Fall Risk Observations dated 01/24/2024, 02/13/2024 and 03/21/24 indicate that R3 is high risk for falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 2 of 3 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 04/11/2024 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)

F 0689 The facility's undated document titled Routine Resident Checks and Safety Room Checks documents, in part: Routine checks shall be made to ensure the resident safety and wellbeing are maintained. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's job description titled LPN (Licensed Practical Nurse)\Charge Nurse documents in part: Purpose: The primary purpose of this position is to: Supervise the day-to-day CNA services for assigned unit to assure that care is being rendered in accordance with current federal, state, guidelines, and regulations . Duties and Responsibilities/Function: 3. Closely monitor and supervise all facility residents per facility policies and as warranted by good nursing judgement. Event ID: Facility ID: 145482 If continuation sheet Page 3 of 3