Health inspection·April 9, 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 ensure a resident with a history of dysphagia was supervised and failed to ensure the recommended swallowing strategies were implemented. This applies to 1 of 8 residents (R11) reviewed for safety. The findings include: R11's face sheet shows she is a [AGE] year old female with diagnoses including aphasia, oropharyngeal dysphasia, type 2 diabetes, progressive supranuclear palsy. R11's Minimum Data Set assessment dated [DATE] shows she requires supervision with eating. R11's Swallowing/Feeding Guideline dated July 12, 2022 documents swallowing supervision-periodic, strategies: eat/feed slowly, small bites/sips, one at a time, check mouth for pocketing of food on the right, check mouth for pocketing on left, chew thoroughly, moisten solids. R11's Speech Language Pathology Quarterly Screen dated 3/13/23 documents swallowing ability: dysphagia, liquids are thickened to nectar consistency, decrease in function, per nursing interview .(R11) with decline in swallowing, cognition, or speech at this time, under hospice care. On 4/8/24 at 12:18 PM, R11 was observed in her room sitting in her recliner chair during the noon meal. She was served a bowl of minced chicken with sauce, puree sweet potato and puree cauliflower. R11 took a bite of the minced chicken and was coughing after the bite, she took another bite of the chicken, and continued to cough. She spit out pieces of the chicken into a tissue and continued to cough several times. This surveyor asked R11 to open her mouth, a quarter size of food was on the top of her tongue. R11 continued to feed herself, and spit food out on the tissue. At 12:24 PM, R11 remained in her room feeding herself. There was no staff observed going into R11's room. R11's coughing was heard from the hallway. Two CNAs (Certified Nursing Assistants) were observed in the dining room at this time and V4 Registered Nurse (RN) was in another resident's room. On 4/8/24 at 1:18 PM, V4 (RN) said R11 does not speak, but communicates with a board or yes/no questions. She has right sided weakness and requires supervision during meals. She tends to have coughing episodes, and tends to put food in her mouth too fast. On 4/9/24 at 10:44 AM, V3 Assistant Director of Nursing (ADON) said R11 likes to feed herself, she is on an altered diet and staff should be checking on her when she is eating. Staff should be checking R11's mouth for any food residual and signs of aspiration. (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 5 Event ID: 146014 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 146014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Harvard Hospital Care Center 901 South Grant Harvard, IL 60033 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)