Health inspection·June 1, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 maintain a hazard free environment. This failure affected one resident (R5) reviewed for safe environment and has the potential to affect all 52 residents residing on the 3rd floor. Findings include: The 05/30/2023 facility census on 3rd floor was 52. On 05/30/2023 at 11:03 AM, there was a medicine cup in the med cart's trash can with multiple medications inside. This observation was brought to the attention of V13 (Clinical Care Coordinator). V13 stated medication should not be thrown in the trash can for safety reason. On 05/30/2023 at 12:01 PM, V17 (Registered Nurse) was later identified as the nurse who disposed of the medications in the med cart's trash can. V17 stated, medications can be disposed of in the medication trash can. V13 (Clinical Care Coordinator) was present during this conversation and stated medications should not be disposed of in the med cart's trash can. On 05/30/2023 at 4:16 PM, V17 stated, the medications were for R5. V17 stated, (R5) agreed for me (V17) to give the medications, I (V17) prepared the medications, I (V17) accidentally dropped some on the floor and some at the top of the medication cart. I (V17) picked up the meds on the floor and on top of the cart and disposed of them in the trash can located at the side of the med cart. I (V17) prepared another set. I (V17) got confused. I (V17) should have not thrown the medications in the trash can; some residents may pick the medications and take them. 3rd floor is skilled nursing floor. We also have confused residents on 3rd floor. On 06/01/2023 at 11:39 AM, V2 (Director of Nursing) stated medication should be disposed of in a closed container or the sharp container because we (facility) don't want any residents and staff, and visitors to have access to the medications. That is a safety issue. If any resident saw it, they may take the medications and we (facility) don't know the side effect of this medications to the residents. The (undated) Residents' Rights for People in the Long-Term Care Facilities documented, in part As a long -term care resident in the (state), you are guaranteed certain rights, protections and privileges according to state and federal laws. Your rights to safety. Your facility must be safe, clean, comfortable and homelike. The (08/2020) Medication Destruction for Non-Controlled Medications documented, in part Policy. (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: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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)