F 0689
Level of Harm - Minimal harm
or potential for actual harm
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 implement fall interventions.
Residents Affected - Some
This applies to 4 of 4 residents R3, R4, R5 and R6 reviewed for falls in a sample of 7.
Findings include:
1. R3 was admitted to the facility on [DATE] with diagnosis that include Chronic Obstructive Pulmonary
Disease and Dementia. R3's MDS (Minimum Data Set) dated 1/17/24 documents a BIMS (Brief Interview
for Mental Status) score of 1 indicating he is cognitively impaired. R3 had a documented unwitnessed fall
on 2/7/24. R3's care plan was updated on 2/7/24 to include floor mats / floor pads at the bedside.
On 3/26/24 at 10:40 AM, R3 was lying in bed. There was no fall mat on floor to the right side of R3's bed.
On 3/26/24 at 11:01 AM, V5 C.N.A. (Certified Nursing Assistant) exited R3's room but did not place the fall
mat on the right of R3's bed. V5 stated R3's fall interventions include a bed and chair alarm, fall mat to the
floor on both sides of the bed, and bed rails. Surveyor informed V5 she did not place the fall mat back on
the right side of R3's bed.
2. R4 was admitted to the facility on [DATE]. R4 has diagnosis that includes Chronic Kidney Disease,
Visuospatial Deficit and Anxiety. R4's MDS dated [DATE] documents a BIMS score of 15 indicating she is
cognitively intact. R4 last documented fall was 2/16/24. R4's care plan for falls dated 1/25/24 included the
use a bed alarm.
3. R5 was admitted to the facility on [DATE] with diagnosis that includes Congestive Heart Failure,
Dementia and Hypertension. R5's MDS dated [DATE] documents a BIMS score of 5 indicating she is
cognitively impaired. R5's had a documented fall on 2/8/24. R5's care plan was updated on 2/8/24 to
include a bed alarm.
On 3/26/24 at 3:45 PM, V8 C.N.A. assigned to care for R4 and R5 stated she had floated to the unit and did
not know what fall interventions were in place for R4 and R5.
On 3/26/24 at 3:52 PM, V8 and another staff member assisted R4 to the toilet. There was no bed alarm on
R4's bed.
(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:
145307
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
145307
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Grove of Lagrange Park, The
701 North Lagrange Road
LA Grange Park, IL 60526
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
On 3/27/24 at 10:35 AM, R4 did not have a bed alarm on her bed.
Level of Harm - Minimal harm
or potential for actual harm
On 3/27/24 at 10:36 AM, V6 RN (Registered Nurse) stated R4 and R5 should have bed alarms in place as
part of their fall interventions. V6 stated it is the responsibility of Nurses, Managers and C.N.As to assure
fall precautions are in place.
Residents Affected - Some
On 3/27/24 at 10:43 AM, V10 C.N.A. was brought to R5's bedside to check the bed alarm and noted it was
off. V10 was then brought to R4's bedside to confirm there was no bed alarm.
4. R6 was admitted to the facility on [DATE] with diagnosis that include Chronic Obstructive Pulmonary
Disease, Hemiplegia, and Ischemic Optic Neuropathy. R6's MDS dated [DATE] documents a BIMS score of
8 indicating a moderate cognitive impairment. R6's care plan dated 2/2/24 includes fall interventions that
include the use of a bed alarm.
On 3/28/24 at 12:06 AM, R6's bed alarm did not have a green light indicating it was on and activated.
On 3/28/24 at 12:15 PM, V12 C.N.A / Admissions Director was in R6's room providing feeding assistance to
another resident. V12 stated she wasn't sure how the alarm worked because the facility used different types
of alarms.
On 3/28/24 at 12:18 PM, V5 C.N.A. assigned to R6 transferred R6 from the bed to a wheelchair. The bed
alarm did not alert. V5 then repositioned the pressure sensing pad attached to the bed alarm and placed
R6 back on the bed. The bed alarm indicator light flashed green and beeped. V5 stated if the resident is not
positioned properly on the pressure sensing pad the alarm will not set and staff will not be alerted if the
resident attempts to get up. R6 then shifted off the pad the indicator light turned red and alarmed.
On 3/27/24 at 11:22 AM, V2 DON (Director of Nursing) stated it is the responsibility of Nurses, C.N.A,
Managers and Activities personnel to assure fall interventions are in place. No staff should be walking away
from residents without assuring measures are in place and working properly.
On 3/27/24 at 11:55 AM, V1 Administrator stated the restorative nurse determines what fall interventions
should be implemented. Any staff that go in a resident's room should assure fall interventions are in place.
They should not walk away without making sure fall alarms are working, mats are on the floor and
interventions are in place.
The Fall Occurrence policy dated 7/17/23 states it is the policy of the facility to ensure that residents are
assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised
as necessary.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145307
If continuation sheet
Page 2 of 2
