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
interviews and record review, the facility failed to ensure the safety of one resident (R3) as two Certified
Nurse Assistants prepared to transfer resident from chair to bed. This failure resulted in R3 falling and
sustaining a laceration to the forehead requiring hospitalization and stitches.
Findings include:
R3 is [AGE] year old with diagnosis including but not limited to: history of falling, presence of artificial right
hip joint, other osteoporosis and fracture of unspecified part of right femur.
During investigation on 3/24/25 at 12:53 PM, R3 was observed lying in bed with a scar on her forehead.
On 3/24/25 at 12:53 PM, V7 (CNA/ Certified Nurse Assistant) said that R3 had fallen from her geri-chair
(geriatric chair) while she (V7) and V6 (CNA) were preparing to transfer R3 to her bed. V7 said, V6 (CNA)
and I were working together to transfer her (R3) because she is a total care patient. R3 was sitting up in her
chair by the bed and I went to go and get the mechanical lift. V6 was standing on the other side of the bed
at that time when R3 leaned forward and fell. I (V7) could not try to catch her (R3) because I was too far
from her.
On 3/24/25 at 12:55 PM, V6 (CNA) said that she (V6) was on the side of the bed when R3 fell and could not
reach her (R3) in enough time to stop her from falling from the chair.
At that time, V6 pointed to the side of R3's bed near the window and said that this is where she (V6) was
standing during R3's fall.
V6 then pointed to the position where R3 was sitting at the time of her fall, which was at the foot of R3's
bed.
Surveyor asked if R3 was reclined or sitting up in the geri chair at the time of her fall.
On 3/24/25 at 12:55 PM, V6 (CNA) said that at the time of R3's fall, R3's chair was not reclined, yet in an
upward position.
Surveyor asked if a staff member should be standing close to R3 in preparation to transfer R3 from her geri
chair to the 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:
145634
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
145634
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Astoria Place Living & Rehab
6300 North California Avenue
Chicago, IL 60659
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
On 3/24/25 at 1:18 PM, V5 (RN/ Registered Nurse) said, R3 has poor trunk support and usually leans from
side to side in the geri (geriatric) chair. R3 also sometimes slides in the chair and is unable to sit up straight.
It is unsafe for her (R3), which is why she is usually reclined in her geri chair. If a staff member was with R3,
the fall may have been prevented.
Residents Affected - Few
On 3/24/2025 at 2:30 PM, V8 (Restorative Nurse) said, R3 has a tendency to slouch and slide in the chair
because she has poor trunk control. Upon inquiry of the process of transferring from bed to chair, V8 said,
One person should be with R3 and applying the slings or guiding the patient, the other CNA is controlling
the lift. Once the patient is in the sling during the transfer, one CNA is guiding the patient and the other
CNA is maneuvering the machine.
Surveyor asked if was safe for R3 to sit upward in a geri chair alone. V8 said that if a CNA (Certified Nurse
Assistant) was standing near R3 prior to the transfer, it would decrease the chances of her falling due to
R3's poor trunk control.
On 3/26/25 at 3:15 PM, V14 (CNA) said that during a patient transfer to bed, a CNA should be within arms
reach of the patient for safety and to prevent the patient from falling.
Surveyor asked if it would be easier for a patient to lean forward in a geriatric chair if the chair is not
reclined.
On 3/27/25 at 12:55 PM, V12 (NP/ Nurse Practitioner) said, a patient with poor trunk control can definitely
sit up and lean forward in a geri- chair depending on how weak or strong the patient is.
Surveyor asked if a fall with head injury may be detrimental to a geriatric patient.
On 3/27/25 at 12:55 PM, V12 (NP) said, Sure, yes it can.
R3's Care plan documents, R3 uses reclining wheelchair for proper body alignment, comfort and
positioning due to poor trunk control; R3 is at high risk for falls; staff instructed to use tactile cueing, holding
on R3's shoulder when R3 is seated on geri chair during showers days, to lower risk of R3 rocking forward.
Section GG- Functional Abilities assessment documents, R3 is dependent on staff for chair to bed
transfers.
Facility Incident Report dated 3/4/25 documents, R3 had an observed fall with injury in resident's room;
CNA reported to the Nurse on duty that R3 leaned forward and fell on the floor; CNA was unable to reach
R3 to stop her from falling; R3 was taken to the hospital and returned to the facility with ten sutures on the
right frontal head.
R3's Hospital visit summary dated 3/4/25 documents, diagnosis: Fall, injury of head and facial laceration.
Facility policy titled Mechanical lift transfers documents, there will always be two staff to assist the resident.
One staff will control the lift as the other will guide resident and support back and neck to transfer surface.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145634
If continuation sheet
Page 2 of 2
