Inspection·March 10, 2025

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 supervise and monitor a cognitively impaired resident with known behaviors of ingesting non-edible, toxic items from obtaining those items. This failure affects one of three residents (R2) reviewed for supervision in a total sample of three residents. Findings include: 03/08/2025, 9:53 AM, R2 was sitting on a chair next to her bed. R2's overbed table was next to her with her personal items within reach. A 4 oz (ounce) baby powder bottle and liquid soap in a clear cup on were her overbed table. 03/08/2025, 11:03 AM, with V2 (Assistant Administrator) present, R2's overbed table observed with baby powder. V5 (Certified Nursing Assistant) entered the room. R2 was questioned who gave you the powder. R2 pointed to V5 and stated that young lady. R2 states that she got the liquid soap from someone at the nurse's station but cannot recall who. 03/08/2025, 10:51 AM, via telephone, V6 (Certified Nursing Assistant) states that she has worked for the facility for three years. V6 reports that she usually works the morning shifts and usually works on the second floor. V6 states that she is familiar with R2. V6 continues to report that R2 needs reminders to take a shower. We make sure she showers. She likes to hold food, but you can't just take away the old food, when she is around, because she is a fighter. V6 states you need to make sure you don't give her baby powder and lotion because she thinks they are condiments and consume them. V6 says it is salt and pepper. 03/08/2025, 11:06 AM, V5 (Certified Nursing Assistant) states that R2 requires minimal assist. Staff provides set up, and gets her the things she needs. She asks for soap. Normally, staff don't give her baby powder. She can do it herself, we just don't give her powder. V5 states that she was changing R1 this morning and R1 had a lot of items on her overbed table. V5 stated I borrowed R2's table. V5 states that the reason R2 cannot have the baby powder within reach is because R2 will probably apply too much powder on herself. V5 states that she denies ever seeing R2 put powder on her food. V5 states I was not made aware that she can put powder on her food. It would be safer for her not to have any powder if that is the case. V5 states I was not aware that she would eat it. I just thought she would sprinkle too much powder on her body. It was a mistake and not intentionally done. 03/08/2025, 12:06 PM, V4 (Director of Nursing) states that it is not safe for an individual to consume soap, lotion, and/or baby powder because it is not to be eaten. V4 states that if she knew R2 had a history of ingesting these certain items, staff should not provide any of those items, unless (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: 145796 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral 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)