Health inspection·August 2, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interviews and record review, the facility failed to provide adequate supervision during provision of ADL (Activities of Daily Living) care for 1 (R2) resident out of 3 residents reviewed for falls. This failure resulted with R2 falling while at the facility on 06/24/2025 and sustaining a facial laceration requiring sutures.Findings include: R2's admission Record documented that R2's diagnoses (include but not limited to) Type 2 Diabetes Mellitus, repeated falls, Alzheimer's disease, dementia, and laceration part of head (Onset Date: 06/25/2025). R2's (05/13/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. Section GG - Functional Abilities. GG0130. Self-Care. E. Shower/bathe self: 02 - substantial/maximal assistance - Helper does more than half of the effort. Helper lifts or holds trunk or limbs and provides more than half of the effort. R2's (Revision Date: 05/24/2025) care plan documented, in part Focus: has a Self-Care Deficit and requires assistance with ADL's to maintain the highest possible level of functioning. Goal: will maintain their current level of ADL functioning without a significant decline. Interventions: Provide assistance with all ADL's as required per the residents need dependence: Bathing.R2's (Revision on: 06/22/2023) care plan documented, in part Focus: is at risk for falls R/T (related to) Cognitive Impairments, Dementia. Goal: will remain free of injuries. Interventions: Staff to redirect resident when they see her bending over picking up anything off the floor (initiated: 09/13/2021). Anticipate and meet individual needs of the resident. (Date Initiated: 05/02/2017). R2's (06/24/2025) Fall documented, in part Person Preparing Report: V3 (Licensed Practice Nurse). Nursing Description: This writer was called by the CNA (Certified Nurse's Assistant) to the west side shower room, pt (patient) found lying on the floor leaning toward the left side, noted 2 lacerations on the left forehead above the left eye, bleeding, pressure dressing applied. 911 call was made, ambulance here to take pt to ER via stretcher. Predisposing Physiological Factors: confused, decreased safety awareness, and decreased strength. R2's (06/24/2025) CT Scan report documented, in part FINDINGS: Soft tissues: Swelling and laceration of the frontal scalp on the left side extending into the left periorbital area. R2's (06/30/2025) Final Reportable documented, in part Summary of Investigative Findings: While being showered by CNA (V4), the resident leaned forward, slipped off the shower chair, and fell, hitting her face on the floor. Resident has poor trunk control causing her to fall and sustain head injury, resident was sent out 911 and returned within 24 hours from ER (Emergency Room) with sutures.On 08/01/2025 at 10:32am with V17 (Licensed Practice Nurse) at the facility's first floor dining/activity room, R2 was seated on a wheelchair. R2 was leaning forward and V17 has to touch and guide R2's chin to show R2's face to the surveyor. R2 was observed with approximately 1mm x 2mm, 2mm x 2mm, and 3mm x 3mm scabbing above the corner of R2's left eyebrow. R2 was making noises, clenching her teeth. R2 failed to interact with the surveyor. V17 stated that she (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: 146062 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 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)