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
interview and record review, the facility failed to ambulate residents with the assistance of a gait belt to
ensure residents were ambulated in a safe manner. This failure applies to 2 of 4 residents (R1, R2) in the
sample of 4 reviewed for safety and supervision. This failure resulted in R1 falling while ambulating with
staff, resulting in R1 fracturing her left femur (upper leg) and requiring hospitalization.
The findings include:
1. The facility's Witnessed Fall incident report, dated 1/10/24, showed R1 was walking in her room, with the
use of her walker and with V7, Certified Nursing Assistant (CNA), present, when R1's knees buckled and
R1 fell to the floor. The report showed R1's left leg got caught under a bedside dresser during the fall. R1
complained of pain to her left leg. 911 was called. R1 was transferred to a local hospital via ambulance.
R1's hospital records, dated 1/11/24-1/15/24, were reviewed. The records showed R1 was admitted to the
hospital with a diagnosis of a displaced distal femoral fracture after sustaining a witnessed fall at the facility.
R1 was discharged from the hospital on 1/15/24, when she returned to the facility.
R1's Fall Scale assessments, dated 10/25/23 and 1/10/24, each showed R1 was at high risk for falls.
R1's care plan, revised on 10/25/23, showed R1 was at risk for falls due to her history of previous falls,
impaired cognition, weakness, and poor vision. The care plan showed, I have a history of bilateral knee
buckling during ambulation . The care plan showed R1 required the extensive assistance of one staff, with
the use of a gait belt, for all transfers and ambulation. R1 was cognitively impaired related to her diagnoses
of dementia and Alzheimer's disease.
On 1/24/24 at 8:30 AM, an attempt to interview R1 about her fall on 1/10/24 was unsuccessful, due to her
impaired cognition.
On 1/24/24 at 9:18 AM, V7, CNA, stated she was the only staff member with R1 when she fell on 1/10/24.
V7 CNA stated she did not have a gait belt on R1 when ambulating her on 1/10/24. V7, CNA, stated, I was
walking with (R1). Her knees buckled and she went down. I think her left leg broke because it got stuck
under the dresser. It happened so fast. I couldn't catch her. I should have been using a gait belt on her. She
complained of pain to her leg right away.
On 1/24/24 at 9:35 AM, V8, Nurse, stated she was called to R1's room, by V7, CNA, on 1/10/24. V8
(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:
145547
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
145547
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dekalb County Rehab & Nursing
2600 North Annie Glidden Road
Dekalb, IL 60115
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
stated, When I got to the room, (R1) was on the floor. She complained of pain to her leg. (V7) did not have a
gait belt on (R1).
Level of Harm - Actual harm
Residents Affected - Few
On 1/24/24 at 11:11 AM, V4, Restorative Nurse, stated staff are to use a gait belt when transferring or
ambulating any resident that requires any level of staff assistance to do so. V4 stated, The purpose of the
gait belt is for staff to help lower a resident to the floor, if they start to fall, to prevent any injury . Prior to
(R1's) fall on 1/10/24, she required the assistance of one staff. with use of gait belt, when walking. She has
a history of previous falls and her knees buckling when she walks.
On 1/24/24 at 11:01 AM, V5, Nurse Practitioner, stated, Staff should refer to a resident's care plan or get
report on how to transfer a resident. All staff should be using a gait belt when transferring or walking a
resident. That is pretty much the standard.
2. The facility's Witnessed Fall incident report, dated 12/21/23, showed R2 was walking in her room, with V6
CNA, when the resident lost balance and began to fall. R2 was assisted to the ground by V6 CNA. R2
received no injuries from the fall. The report showed, Resident lost her balance while ambulating with staff.
Staff to use gait belt .
R2's Fall Scale assessment, dated 12/19/23, showed R2 was at high risk for falls.
R2's care plan, revised on 6/29/23, showed R2 was at risk for falls due to her history of repeated falls,
impaired cognition related to her dementia diagnosis, obesity, and generalized weakness. The care plan
showed, I need limited-extensive assistance from one staff member with one of their hands on my gait belt
during ambulation.
On 1/24/24 at 9:40 AM, V6, CNA, stated she was the only staff member with R2 when she fell on [DATE].
V6 CNA stated she did not have a gait belt on R2 when ambulating her on 12/21/23. V6, CNA, stated, We
were walking back from the bathroom. She was using her walker. (R2) started to lose her balance and went
down. I tried to catch her and guide her to the floor. I grabbed her arm and under her butt to lay her down
on the floor. I was not using a gait belt. I should have been.
On 1/24/24 at 11:11 AM, V4, Restorative Nurse, stated R2 required the use of a gait belt, one staff member,
and a walker when ambulating due to her history of previous falls.
The facility's Transfer/Gait Belt policy dated March 2015 showed, Gait belts/Transfer belts are to be properly
used in the transfer and ambulation of any resident needing assistance with those activities.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145547
If continuation sheet
Page 2 of 2
