Inspection·May 8, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update a resident's care plan that was high risk for falls to include fall prevention interventions after a fall for one resident (R1) out of 3 residents reviewed for fall prevention. Findings include: R1's face sheet documents that R1 has the following medical diagnosis including but not limited to other lack of coordination, chronic obstructive pulmonary disease with (acute) exacerbation, plantar fascial fibromatosis, corns and callosities, generalized anxiety disorder, and post-traumatic stress disorder. R1's Minimum Data Set (MDS) dated [DATE] shows that R1 has a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R1 is cognitively intact. On 05/06/24 at 12:14 pm, R1 was observed ambulating in R1's room into the hallway without assistance and with an unsteady gait. R1 stated, I (R1) keep falling at the facility and nothing is being done about it. R1 would not stop to speak with Surveyor and Surveyor was not able to ask R1 questions. R1 ambulated down the hallway stating, They are trying to keep me in a wheelchair, but I (R1) won't let them do it. On 05/06/24 at 12:15 pm, V7 (Registered Nurse/RN) stated that V7 is R1's nurse every day at the facility. When V7 was asked regarding R1 falling at the facility V7 stated that R1's last fall was a few months ago at the facility and that R1 is a fall risk. V7 stated that V7 recalls R1's last fall a few months ago when V7 observed R1 sitting on the floor in the hallway outside of R1's room. V7 stated that V7 did not observe R1 with any injuries, R1 denied hitting R1's head and that R1 was not sent to the local hospital for an evaluation. When V7 was asked regarding R1's fall interventions at the facility that were implemented after R1's fall on 02/17/24, V7 stated, R1 does not have fall interventions because R1 does not fall a lot at the facility. On 05/07/24 at 1:07 pm, V2 (Director of Nursing/DON) stated that V2 does not interact with R1 due to R1's preference. V2 stated that R1's last fall at the facility was on 02/17/24 when R1 was found sitting on the floor outside of R1's room. V2 explained that R1 was assessed without injury and was not sent to the local hospital due to the fall. When V2 was asked regarding R1's fall interventions implemented from R1's fall on 02/17/24. V2 stated, I (V2) don't see any interventions that were placed for R1's fall on 02/17/24. Can you ask V13 (Falls Nurse, License Practical Nurse). She (V13) is the one responsible for implementing fall interventions after a resident has a fall. When V2 was asked (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: 145670 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 North Sheridan Road Chicago, IL 60626 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)