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 provide safe transfer assistance. This failure resulted in R1
sustaining left and right femoral fractures. This applies to 1 of 3 residents (R1) reviewed for safe transfers.
Findings include:
R1's Medical diagnosis from the electronic record documents R1 as a [AGE] year old with diagnoses to
include a right and left periprosthetic fracture around both artificial knee joints, dementia and physical
disability.
On 05/02/2024 at 11:18 AM, V13 Hospital staff stated Before these fractures, (R1) could not bear weight,
she was contracted and unable to stand up on her own. She was bedbound.
On 04/30/2024 at 02:17 PM, V9 Certified Nursing Assistant (CNA) stated That morning I got (R1) up out of
bed like I always do. I put my arms under her armpits and did the pivot transfer. I felt her become dead
weight then. Her knee seemed like it was swelling. I told the nurse (V6 Licensed Practical Nurse [LPN]).
Then I took her down to the shower room and gave her a shower. The other knee was starting to swell up
then, so I made sure the nurse knew what was going on.
On 04/30/2024 at 11:00 AM V6 LPN stated (R1) is a one person assist for transfer. She's a pivot transfer.
We don't always use a gait belt; it seems to cause (R1) pain when we do. We just put our hands under her
arm pits and transfer.
The Final Report to Illinois Department of Public Health dated 04/22/2024 documents under Summary
CNA stated 'When I got to the room to get the resident up to the shower room, the resident was transferred
by placing both arms under the patient's armpits to pivot and transfer.' The CNA stated she felt patient dead
weight and sat the resident down in wheelchair. The CNA noticed when putting the gown on the resident,
there was swelling observed to the left knee and the resident stated that there was pain to the left knee
also. Under Summary of the Investigation, it documents All the staff from the day before (04/21/2024)
stated they did not notice any swelling to the left or right knee. Xray's bilateral legs were ordered. The
results stated there were fractures to both legs.
The Radiology Results Report for R1 dated 04/22/2024 at 01:00 and 01:13 PM document under Findings:
Right knee- There is an acute versus subacute comminuted fracture of the distal femur, immediately
proximal to the distal femoral prosthesis with angulation. Left knee- There is an acute distal femoral shaft
fracture, located immediately adjacent to the prosthetic femoral component of total knee
(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:
145657
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
145657
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pearl of Downers Grove
3450 Saratoga Avenue
Downers Grove, IL 60515
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
replacement, which remains in anatomic alignment.
Level of Harm - Actual harm
The care plan for R1 dated 09/02/2023 and reviewed 03/05/2024 documents Transfer : The resident
requires (SPECIFY what assistance) by (X) staff to move between surfaces (SPECIFY FREQ) and as
necessary. Date Initiated: 09/02/2023 Revision on: 10/07/2023; which was incomplete and did not specify
R1's individualized transfer needs.
Residents Affected - Few
On 05/02/2024 at 10:45 AM, V2 Director of Nursing stated Transfer status is determined by the physical
therapist. We monitor the residents everyday. The staff will notify nursing if a resident has a change in ability
so the resident's transfer status can be reassessed. That information is then used in the care plans. The
care plan for (R1) isn't updated. That is why there is no direction for transfers.
On 05/01/2024 at 02:30 PM, V5 Physical Therapist stated The gait belt should always be used for every
transfer. Anything else is not a safe transfer.
On 05/01/2024 at 11:25 AM, V4 Medical Director stated (R1) has a lot of medical issues and has declined
recently. She is very contracted on both legs. The injury may be the result of a forceful transfer.
The undated Activities of Daily Living policy documents under Mobility (transfer and ambulation, including
walking) i. Residents will be assisted with transfer and mobility as ordered by the physician/practitioner
and/or as instructed in the resident's care plan
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145657
If continuation sheet
Page 2 of 2
