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
observation, interview, and record review the facility failed to ensure a resident was safely transferred for 1
of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a laceration
of 11 centimeters (cm) requiring 13 sutures.
The findings include:
R1's face sheet printed on 11/4/24 showed she was [AGE] years old and diagnosed with dementia,
malnutrition, and peripheral venous insufficiency.
A facility assessment done on 8/29/24 showed R1 had severe cognitive impairments and was dependent
on staff for transfers.
R1's Care Plan printed on 11/4/24 showed R1 had a self-care deficit and impaired mobility. Listed under
interventions showed R1 was dependent on two staff for transfers. The same care plan showed R1 had a
cognitive deficit such as poor safety awareness, decreased comprehension, and impulsiveness. Listed
under intervention was to modify environment as needed.
On 11/4/24 at 9:05 AM, R1 was in bed. R1's left leg near her shin showed a dark line/scar about 8 cm long.
The dark line/scar was toward the outside of R1's leg towards her knee. There were two grape size swollen
dark areas next to the dark line/scar.
On 11/4/24 at 9:05 AM, V5 (Certified Nursing Assistant- CNA) said the dark/scar area occurred while V5
transferred R1 from a shower chair. V5 said she and V6 (CNA) were transferring R1 with a mechanical lift
when R1 kicked her left leg out hitting the mechanical lift causing a laceration. V5 said every once in awhile
R1 will kick her legs while being transferred. V5 said R1 will sometimes follow direction and the day of the
incident R1 was not following direction.
A written statement by V5 dated 10/3/24 showed on 10/2/24 while R1 was in a sling being transferred she,
.accidentally bumped her left shin onto the base of the [mechanical lift] .
On 11/4/24 at 10:05 AM, V6 said on 10/2/24 after R1 received a shower he was asked by V5 to assist in
transferring R1 from a shower chair to a wheelchair. According to V6, he was moving the mechanical lift
and V5 was guiding R1 by being positioned by R1's trunk. V6 said R1 moved her left leg during the transfer
hitting the main bar of the mechanical lift. V6 said R1 was lowered back into the shower chair and R1 was
moved to her room while in the shower chair. Once R1 was in her room, she was transferred with a
mechanical lift into bed. V6 said once R1 was in bed, V6 and V5 noticed R1's left
(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:
145678
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
145678
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bella Terra Schaumburg
675 South Roselle Road
Schaumburg, IL 60193
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
leg was bleeding, and they got the nurse.
Level of Harm - Actual harm
On 11/4/24 at 10:52 AM, V7 (Wound Care Nurse) said R1 sustained a laceration and two hematomas to
her left leg during a transfer done on 10/2/24. V7 said the laceration was about 10 cm long and required 13
sutures to close. V7 added that R1 had a history of getting agitated with care.
Residents Affected - Few
On 11/4/24 at 11:19 AM, V9 (CNA) said when transferring a resident with a mechanical lift it takes two staff
members. One staff member will move the mechanical lift and the second staff member will guide the
resident to ensure there are no accidents.
On 11/4/24 at 1:01 PM, V10 said the hematoma found on 10/1/24 could have happened during a transfer.
V10 added that R1 had dementia and can be restless a times.
R1's Progress Note dated 10/2/24 showed R1 had a left shin laceration with moderate amount of bleeding.
The note indicated the laceration was 11 cm x 2 cm x 3 cm and R1 was sent to the emergency room.
R1's emergency room notes dated 10/2/24 showed she had 13 sutures placed to close the laceration. The
same notes showed an x-ray report indicated, .soft tissue swelling anterior to the proximal tibia .
R1's health care provider progress note entered by V10 (Physician) dated 10/1/24 (one day before R1
sustained a laceration) showed R1 was seen for a hematoma to her left leg that was about the size of a
grape to R1's anterior shin that had swelling and bruising. Staff found the hematoma during a transfer. The
note indicated that the hematoma was likely caused by, .trivial trauma .
On 11/4/24 at 1:15 PM, V1 (Administrator) said after the incident on 10/2/24 where R1 sustained a
laceration during a transfer, padding was added to the mechanical lifts.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145678
If continuation sheet
Page 2 of 2
