Inspection·June 9, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and update resident's fall care plan with new interventions to prevent one resident (R6) who was a risk for falls, from falling and hitting her head on 1/23/23. This failure effects 1 resident of 3 residents reviewed for falls in a sample of 12. Findings include: R6 post fall occurrence forms document three falls 11/21/22, 12/8/22, and 1/23/23. R6's fall-initial occurrence report for 11/21/2022 documents R6 tried to get up but slid off the bed. R6 was found sitting on the floor with legs outstretched on the side of her bed. R6's fall-initial occurrence report for 12/8/2022 documents R6 was found face down on the floor, resident stated she lost her balance and fell, and precipitating factors: resident needed to void and forgets to use the call light and is on an anticoagulant. R6's Fall initial occurrence report for 1/23/23 documents R6 was found on the floor in her room lying on her back and head on the floor. R6 stated she was trying to go to the restroom. R6's Progress note dated 12/8/2022 documented a bruise to the forehead and was sent to the hospital. R6's hospital records dated 12/8/2022 document diagnosis as fall and traumatic hemorrhage of cerebrum. Resident was readmitted to the facility on [DATE]. There are no new interventions documented on the fall risk care plan after 7/13/22 until 1/23/23. Therefore, no new interventions after the 11/21/22 fall or the 12/8/22 fall with injury. 6/07/23 01:22 PM V2 (DON) stated after resident's fall, the facility came up with interventions and updated the resident's care plan with new interventions. The facility's Comprehensive Care Plan policy dated 11/17/17 documents the following: to develop a comprehensive care plan that directs the care team and incorporates the resident's highest practicable physical, mental, and psychosocial well-being. The facilities fall prevention program policy documents the care plan interventions are changed (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: 145839 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 145839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Healthcare Center 665 Busse Highway Park Ridge, IL 60068 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)