Health inspection·March 25, 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 implement fall precaution interventions for one (R2) resident identified as a fall risk out of three residents reviewed for fall precautions. Findings include: On 03/23/2024 at 9:02AM, surveyor observes a yellow star on R2's door next to R2's name. R2 observed lying in R2s' bed resting inside of R2s' room in a supine position with head of bed elevated at 45 degrees. R2s' floor mat was observed located in between two closet cabinets leaning against them in R2's room. R2's bed also observed to not be in the lowest position. On 03/23/2024 at 9:08AM, V5 (Agency Certified Nursing Assistant/CNA) states she works for an agency and this is the first time she has ever worked at the facility. V5 states she is the CNA responsible for caring for R2. V5 states she is aware that the yellow stars next to resident names indicate the resident is a fall risk. V5 states she was made aware by V4 (LPN) that V5 (Agency CNA) should watch those residents closely. V5 states she is not familiar with all the resident's fall precaution interventions. V5 states she is aware that she has only one major fall precaution resident to watch closely (identified as R4). V5 states R4 is the only resident she implemented fall precautions for. On 03/23/2024 at 9:15AM, V4 (Licensed Practical Nurse/LPN) located inside of R2's room and observes R2s' floor mat is not in place next to R2's bed. V4 also observes R2's bed was not in the lowest position. Surveyor observes V4 attempting to lower R2's bed and V4 states R2's bed remote is not working and R2's bed cannot be lowered. V4 states she has to call maintenance to fix R2's bed remote. V4 states R2 is a fall risk and R2's floor mat should have been on the floor next to R2's bed. V4 also states R2's bed should always be kept in the lowest position. V4 states if these fall precaution interventions are not implemented, then R2 can fall and hurt herself. On 03/23/2024 at 1:15PM, V8 (Fall Coordinator/RN) states she is the fall coordinator and has been working at the facility since November 2022. V8 states when a resident is admitted , they are assessed for their risk for falls by completing a fall risk assessment. V8 states the facility checks to make sure the residents are assessed for proper fall risk interventions and those interventions are then implemented. V8 states fall risk interventions are documented in the resident care plans. V8 states the yellow stars on the resident's doors are fall risk identifiers. V8 states in an effort to ensure staff is made aware of resident's fall precaution interventions, there is a stand up and stand down meeting held everyday, especially on the 4th floor. V8 states there is a green binder kept at every nurses' station that serves the purpose of a Fall communication tool for the nurses and CNAs. V8 states the green binders lists the residents who are on fall precautions, their acuity level, and (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: 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 03/25/2024 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)