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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure wheelchair pedals were in place prior
to propelling a resident in a wheelchair for one of three residents (R1) reviewed for falls on the sample list of
three. This failure resulted in R1 falling from the wheelchair onto the tile floor and suffering a subarachnoid
hemorrhage that required an overnight hospital stay.
Findings Include:
R1's Care Plan dated 05/09/2025 documents R1 is diagnosed with Dysphagia, Unspecified Psychosis,
Dysarthria following Cerebral infarction, Hemiplegia, Muscle Weakness, Seizures, Major Depressive
disorder, Unsteadiness on Feet, Other abnormalities of gait and mobility, lack of coordination, History of
Falling, unspecified Dementia, and Diabetes.
R1's Care Plan dated 05/09/2025 documents R1 is at risk for falling related to weakness. R1's care plan
does not document R1 as dependent for wheelchair mobility or interventions for R1 for refusing to use foot
pedals during transfers/propelling by staff.
R1's Physician Order Sheet dated June 2025 documents R1 was prescribed an anti-platelet medication in
of February 2025.
R1's Minimum Data Set documented as completed on May 8, 2025, documents under section C completed
on April 30, 2025, that R1 is cognitively intact. Section GG completed on May 8, 2025, documents that R1
uses a wheelchair and requires substantial/maximal assistance for transfers, bed mobility, and activities of
daily living.
V2's, (Director of Nursing (DON)), Progress Note dated 5/8/2025 at 10:37 AM documents on 5/7/25 at 4:31
PM R1 was in the dining room on the floor on R1's left side. The same note further documents R1 was in
her wheelchair, being transported by an activity aide (V7) to her room to be changed prior to the fall.
V10's (Registered Nurse) Progress Note dated 5/8/2025 at 05:39 AM documents R1 was admitted to the
intensive care unit for subarachnoid hemorrhage.
R1's After Visit Summary dated 5/8/25 at 1:55 PM from the local hospital documents R1 was admitted to
the hospital on [DATE] after a ground level fall and that a Computed Tomography scan of R1's brain
documented a small acute subarachnoid hemorrhage over the right frontal lobe anteriorly and a large left
frontal subcutaneous hematoma.
(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:
145031
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
145031
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/02/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Normal
510 Broadway
Normal, IL 61761
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)
F 0689
Level of Harm - Actual harm
Residents Affected - Few
On 5/28/25 at 09:45 AM R1 was sitting in the common area in her wheelchair with foot pedals attached to
the wheelchair. R1 had a half dollar sized raised hematoma on the left side of her forehead. R1 was only
alert to person and place.
On 5/28/25 at 11:45 AM V7, Activity Assistant, stated V7 was propelling R1 in the wheelchair from the table
in the dining room to take R1 to her room to be changed due to being incontinent of urine and R1 put her
feet on the floor while R7 was propelling the wheelchair and R1 fell forward from the wheelchair and hit her
head on the floor. V7 stated R1 did not have foot pedals on the wheelchair and is dependent on staff to
propel R1 around the facility.
On 5/28/25 at 10:34 AM V3 Occupational Therapy, stated every wheelchair issued has foot pedals. V3
stated R1 has had foot pedals for the wheelchair for a long time but that they are not often used. V3 stated
R1 has been known to refuse foot pedals on occasion.
On 5/28/25 at 11:38 AM V8, Certified Nursing Assistant, stated R1 does not self-propel the wheelchair. V8
stated V8 does not recall R1 having foot pedals prior to the fall of 5/7/25. V8 stated R1 now has foot pedals
attached to the wheelchair.
On 5/28/25 at 11:40 AM V9 Certified Nursing Assistant, Stated R1 did not have foot pedals prior to the
documented fall of 5/7/25 and did not self-propel wheelchair. V9 stated staff propelled R1 around the facility.
V9 confirmed it was possible for R1 to have fallen and hit her head at any time due to the non-use of foot
pedals.
On 5/28/25 at 1:30 PM V2 Director of Nurses (DON) confirmed V7 was propelling the wheelchair when R1
fell and the wheelchair R1 was using did not have foot pedals on at the time of the fall.
On 06/02/2025 at 11:45 AM V11, Certified Nurse Assistant, stated R1 has not propelled herself in a very
long time and is dependent on staff for mobility in the wheelchair.
The facility's Fall Prevention Program dated 02/12/2025 documents the program's purpose is to assure the
safety of all residents in the facility and is to include measures which determine the individual needs of
each resident by assessing the risk of falls, implementing appropriate interventions to provide necessary
supervision, and using assistive devices as necessary. A Fall Risk Assessment should be performed at
least quarterly and with each significant change in mental or functional condition and after any fall incident.
Safety interventions should be implemented for each resident identified at risk. Section J. documents to
Provide additional interventions as directed by the resident's assessment, including but not limited to: 1.
Assistive devices.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145031
If continuation sheet
Page 2 of 2
