Health inspection·June 18, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident has the right to be free of neglect in one (R1) of three (R1, R2 and R3) residents reviewed in a sample of 10 residents. Findings include: R1 is a [AGE] year-old female with a diagnosis including Cerebral Infarction, Anxiety Disorder, Acute Kidney Failure, COPD, Hemiplegia and Hemiparesis affecting Left Dominant Side. R1 was admitted to the facility on [DATE]. R1 is assessed as a high risk for falls. R1 is care planned for falls. Care plan states R1 lowers herself from the bed to the floor when displaying behaviors where resident gets agitated and anxious. Floor mats are placed on both sides of bed. Bed is kept in its lowest position. R1 is also care planned for behavior of trying to get out of her bed without pulling her call light for staff assistance r/t depression and anxious behavior. R1 has a BIMS (Brief Interview for Mental Status) of 10/15. On 6/16/23 at 1:40PM R1 stated I fell off bed and lay on the mat for around two hours. The nurses were in the room but didn't put me back in the bed. I didn't get hurt. I wanted to go back in my bed, but the nurse wouldn't let me. R1 Behavior progress note 5/12/23 states Behavior: The Agency CNA reported to the writer that resident kept sliding from her bed throughout the shift. Nurse progress note 5/12/23 states: Staff Reported to NOD that Resident was on the floor mat. When asked how she got on the mat resident said I slipped from the bed to the floor. I wanted to walk and get home to my mom. Bed was in the lowest position. NOD asked resident if she hit her head, but she denied and also denied having any pain. Resident was assessed no visible bruises nor laceration noted. Resident seemed more comfortable on the mat and requested to be left on the mat and was later moved back to her bed. Nurse investigation document dated 5/12/23 states: Description: Resident informed R1's husband that she had been on floor for a few hours last night and CNAs went to help her but V5 (Nurse) stopped CNAs from assisting her to bed because she states, she was comfortable and sleeping on the mat on the floor and that she wanted resident to calm down and de-escalate before staff attempted transfer. Resident Description: R1 stated I wanted to go to bed. Upon re-interview, resident stated, I wanted (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: 145776 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 145776 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640 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)