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.
Based on observation, interview, and record review the facility failed to implement fall prevention
interventions for a high-fall risk resident.
Residents Affected - Few
This applies to 1 out of 3 (R1) residents reviewed for falls.
The findings include:
On 5/24/2025 at 9:40 AM, R1 was in bed sleeping. R1 was confused and non-interviewable. R1 did not
have floor mats in place. Then at 10 AM, V16 (Certified Nurse Assistant/CNA) and V17 (CNA) provided R1
with her morning care and transferred her into her wheelchair. R1's wheelchair had a regular black cushion
with no non-slip device in place. V17 said R1 was confused and a high-fall risk. V17 said R1 had recently
slid from her wheelchair. V17 said residents had posted Caregiver communication sheets to inform staff
how to care for them. V17 said R1's posted Caregiver communication sheet included fall interventions. R1's
Caregiver communication sheet dated 5/09/2025 said R1 should have fall prevention devices including floor
mats, dycem (non-slip device), and specialized positioning wheelchair cushion.
On 5/28/2025 at 10:40 AM, V10 (Activity Aide) said he was responsible for supervising residents in the
main dining room. V10 said R1 required constant redirection because she would frequently fidget and lean
forward unsafely in her wheelchair. V10 said he was present when R1 slid off her wheelchair on 5/04/2025
and 5/19/2025 in the dining room. V10 said he attempted to redirect R1 but was unable to reach her quickly
enough to prevent her from falling.
On 5/28/2025 at 12:30 PM, V4 (Restorative Nurse) said R1 continuously displayed poor safety awareness
and was a high-fall risk. V4 said R1's recent fall incidents from 5/04/2025 and 5/19/2025 were investigated
to identify their root causes. V4 said R1's identified root causes for her falls were related to her poor
positioning when in her wheelchair. V4 said the facility reviewed and implemented new interventions to R1's
fall prevention care plan on 5/09/2025. V4 continued to say resident-specific fall interventions were posted
in the residents' Caregiver communication sheets to ensure staff were aware to implement them.
On 5/28/2025 at 12:00 PM, V2 (Director of Nursing) said she expected staff to implement and follow
resident fall prevention interventions as indicated in their fall care plan to minimize their risk for additional
falls.
R1's fall care plan last revised on 5/09/2025 said R1 was a high fall risk because of her limited mobility,
general weakness, dementia with behaviors, and history of falls. R1's fall care plan had
(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:
145405
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
145405
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bria of Westmont
6501 South Cass
Westmont, IL 60559
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
multiple active interventions including providing floor mats initiated on 7/27/2022, a dycem (non-skid)
device on the wheelchair initiated on 3/08/2025, and placing a specialized fall prevention wheelchair
cushion to promote proper alignment and positioning when in wheelchair initiated on 5/09/2025.
R1's Fall Incident report dated 5/04/2025 said Resident was noted by activity staff scooting herself forward
in her w/c causing her to slide forward out of the w/c onto the floor. The report said R1 did not sustain an
injury from the fall incident. The report said the identified root cause of R1's fall was related to her poor
positioning when sitting in her wheelchair. The report said R1's new fall prevention intervention was a
specialized fall prevention wheelchair cushion.
R1's Fall Incident report dated 5/19/2025 said Staff reported resident fell forward out of her wheelchair. The
report said R1 hit the left side of her head but did not sustain a major injury. The report said the identified
root cause of R1's fall was related to her unsafely leaning forward in her wheelchair. The report said R1's
new fall prevention interventions included for staff to continue with R1's prior interventions.
The facility's policy titled Fall Prevention and Management dated 08/2024 said This facility is committed to
maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not
possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies,
and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's
existing plan of care shall be evaluated and modified as needed .Care plan to be updated with a new
intervention based on root cause analysis after each fall occurrence.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145405
If continuation sheet
Page 2 of 2
