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 observation, interview, and record review, the facility failed to transfer a resident safely from a
shower chair. This failure resulted in R1 sustaining a left tibial fracture after a fall in the shower room. This
applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3.
The findings include:
R1's Face sheet shows diagnoses of diabetes with diabetic neuropathy, cerebral infarction, repeated falls,
muscle weakness, and lack of coordination. R1's MDS (Minimum Data Set) dated 7/20/23 shows her
cognition is intact.
On 12/28/23 at 9:52 AM an observation was made of the main shower room where R1's fall occurred.
There are 3 shower stalls on the right-side wall, and 1 shower stall on the left wall. The last/furthest shower
stall on the right side has an approximately 4-foot-long horizontal grab bar, which is about 6 inches to the
left of the shower, above the tile floor.
On 12/27/23 at 11:15 AM, R1 said at the time of her 9/14/23 fall, there was a towel on the floor, and she
told V7 (CNA/Certified Nurse Assistant) that she thought she was going to fall if she tried to stand up. R1
said the next thing she knew, she had fallen and landed on her butt with her legs out in front of her. R1 said
she thinks she fell because the towel under her feet slipped out and her feet slipped too. On 12/28/23 at
9:36 AM, R1 said the fall took place in the main shower room, outside of the last/furthest shower on the
right-hand side while she attempted to stand up using the grab bar outside of the shower stall. On 12/28/23
at 1:57 PM, R1 said at the time of her fall she had bare feet and was not wearing any non-skid socks or
slippers. R1 said she did not fall because of her knee buckling or her hand slipping off the grab bar, she fell
immediately and was never able to stand upright.
On 12/28/23 at 10:25 AM, V7 (CNA) said she put a towel down on the floor before attempting to help R1
stand up. V7 said she was watching R1's hands on the bar when she fell and did not notice what happened
with her feet. On 12/28/23 at 11:28 AM, V7 said R1 was not wearing non-skid socks or slippers at the time
of her fall. V7 said R1 had bare feet, and a gait belt was not used.
R1's nurse's note dated 9/14/23 at 21:55 (9:55 PM) shows that at 2100 (9 PM), resident was observed in
shower room laying on her right side and complaining of pain to her left leg. When the nurse asked the
resident what happened, R1 said, as she was beginning to stand holding the bar in shower room, her foot
slipped, and she fell down. The CNA was unable to prevent the fall and placed a dry towel on the floor, but
R1 still slipped. R1's hospital record documents left lower leg x-ray completed on 9/15/23 at 8:25 AM had
finding of comminuted oblique fracture mid tibial diaphysis.
(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:
145536
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
145536
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Citadel of Bourbonnais,the
20 Briarcliff Lane
Bourbonnais, IL 60914
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 12/27/23 at 2:03 PM, V5 (CNA), said when she gives a resident a shower in the shower room, she will
dry the floor with towels and then remove all towels before the resident stands up. V5 said, I always remove
the towels because I don't want the resident to slip, especially because they don't have any shoes on and
are barefoot. I was trained to wipe the floor up and remove the towels before having the resident stand up.
On 12/27/23 at 2:24 PM, V6 (CNA) said before transferring a just-showered resident from the shower chair
into their wheelchair, I secure the area. I make sure the floor is dry and transfer her with gait belt and lift
from shower chair to her wheelchair. I dry the floor and remove all of the towels, I don't leave a dry towel
down for the resident to stand on. That would be a safety issue, the resident could slip on the towel.
R1's Care Plan dated 11/8/23 shows R1 has a risk for falls related to weakness. Interventions include
ensure R1 is wearing appropriate footwear (slip resistant socks and/or shoes) when ambulating or
mobilizing in wheelchair and R1 needs a safe environment free of clutter. This same Care Plan shows R1
has had previous falls on 12/31/22, 3/26/23, 8/11/23, and 9/14/23. The 9/14/23 fall states, Resident was
standing up from the shower chair when her foot slipped, and she fell. She sustained a left tibia fracture.
R1's final incident report dated 9/22/23 at 10:00 AM shows that on 9/14/23 resident was observed on the
floor lying on her right side. When asked what happened, resident stated as she was beginning to stand
holding onto the bar, her foot slipped, and she fell. NP notified and resident sent out to ER. Report of a
closed fracture to left tibia received and resident returned to the facility after left tibial nailing surgery.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145536
If continuation sheet
Page 2 of 2
