Inspection·October 25, 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 interviews and record reviews, the facility failed to follow care plan interventions to provide adequate supervision as per facility policy, to avoid fall accidents for 1 (R2) out of 3 residents, in a total sample of 3 residents reviewed accidental hazards. This failure resulted to R2 sustaining a frontal lobe hematoma which led to intraparenchymal hemorrhage. Findings include: R2's MDS Section C (10/4/2024) documents in part: R2 has BIMS (Brief Interview for Mental Status) score of 11. R2 is moderately impaired cognitively. Per R2's Facesheet, R2's diagnosis consist of, bilateral osteoarthritis of the hips, muscle wasting atrophy, difficulty walking, heart failure, history of falling, essential hypertension, cardiomegaly. On 10/23/2024, at 11:25 AM, V10 (Falls Coordinator) stated she is familiar with R2. V10 stated R2 is currently in the hospital. V10 stated that R2 is a max assist. Therapy can assist R2 by himself, but they would know better what her transfer status is. V10 stated that on 10/1/2024, R2 tried to get out of bed unassisted. She was in between the bed and the radiator. Her legs were suspended and against the radiator. Her back was to the edge of the bed and her legs were against the wall. She was on her way down. V10 stated that when the resident changes positions and is on their way down, it is considered a fall. The staff who found her was V11 (Certified Nursing Assistant). Her bottom never touched the floor. She went out on the 2nd and came back on the 4th. V10 stated they concluded from their investigation that R2 tried to get out of bed, but she is unable to walk on her own. The fall was at 8:15 AM in the morning. She did sustain an injury after the fall. She had a left subdural hematoma, but no staff member saw R2 hit her head on the floor. V10 stated that R2's fall interventions after the fall were, R2 was moved closer to the nurse's station. V10 stated that R2 had a prior fall on 08/02/2024. V10 stated that after that fall, R2's fall interventions were updated to; R2 should be up in common areas for meals and when not asleep in bed. V10 stated that breakfast is served at 8:00 AM and R2 was still in the bed around 8:15 AM. V10 stated if R2 was gotten up by a staff member then that would have prevented her from getting up on her own and a fall. Around 7:00 AM is when the morning staff comes, and they do the morning routine of getting the residents up. Given her history, she is someone of high priority to get up in the morning so that she is not alone in bed. V10 stated R2's scheduled nurse and certified nursing assistant (CNA) for 10/1/2024, from 7:00 AM to 3:00 PM was V15 (CNA) and V16 (Licensed Practical Nurse). V10 stated she did not get a witness statement from V16. (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: 145632 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 145632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr South Loop 1725 South Wabash Chicago, IL 60616 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)