Health inspection·April 28, 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 observation, interview and record review the facility failed to provide adequate supervision to prevent a fall during incontinence care for one (R1) of three residents (R1, R3 and R4) reviewed for falls. This failure resulted in a fall by R1 who sustained a laceration on the forehead and was sent to the hospital emergency room receiving stitches to repair the laceration. Findings include: R1 is a [AGE] year old male resident with a diagnosis including COPD, Paranoid schizophrenia, Heart failure, Diabetes 2, Anxiety disorder, Depressive disorder severe with psychotic features and Obesity. R1 has a BIMS (Brief Interview for Mental Status) score of 12/15. R1's Minimum Data Set section GG scores 1 (Dependent) for toileting, 2 (Substantial / Maximal assistance) for Shower/bath self and 2 (Substantial / Maximal assistance) To roll left and right. R1's care plan dated 4/16/24 shows R1 is at risk for deterioration in bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene. R/T weakness and poor skills. Requires extensive/total staff assistance. R1 is a high risk for falls R/T weakness, poor bed mobility poor safety awareness. R1's 4/21/24 progress note states resident is alert and oriented. Resident was being changed by CNA and accidentally rolled out of bed. Resident has an open area to the right side of his forehead. Resident noted lying on stomach and hitting head on the floor. Forehead cleaned and pressure applied to open area by staff while waiting for ambulance to arrive to take to hospital. Full Body assessment performed. Resident Eyes are reactive to light, Neurological checks provided, and level of conscious is normal. Resident skin is warm to touch and has laceration to left side of forehead. Resident Mucous membrane pink and moist, and no open area to mouth. Resident lung sounds in normal limits, and no respiratory distress noted. Resident heart rate with normal limits. Resident has full range of motion to upper and lower extremities, and no bruise, redness, or open areas to extremities. Resident Abdomen is soft and round, bowel sounds present times 4 quads, and no distention noted. Resident is assisted into bed with 2 person assistance and pressure to the open wound on the forehead to continue to be applied till 911 arrives. Resident has no complaints of pain or discomfort. ADON and Guardian Notified. Physician is notified and gave order to send to hospital. R1's hospital record dated 4/21/24, shows R1 sustained a right forehead laceration, 5 cm laceration to right side of forehead. This required 13 stitches to repair. Facility incident report dated 4/26/24 shows, on 4/21/24 approximately 2:35pm, R1 had a witnessed (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: 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 04/28/2024 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)