F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to safely transport a resident in their wheelchair.
This applies to 1 of 5 residents (R1) reviewed for safety in a sample of 5.
The findings include:
R1's Facility assessment dated [DATE] showed R1 is an eighty-year-old female with severe cognitive
impairment. R1 admitted to the facility on [DATE] with diagnoses which include severe dementia with
agitation.
The facility's Final Incident Report dated 5/12/25 showed on 5/6/25 at 6:15 PM R1 had fallen forward from
her wheelchair which resulted in R1 receiving 3 sutures above her right eye.
On 5/14/25 at 10:30 AM, R1 was sitting with V5, (R1's Power of Attorney-POA), at the end of the hallway.
R1 was in her wheelchair with her legs behind the leg rests with her feet flat on the ground. R1 had 3
sutures along her outer right eyebrow closing a laceration approximately a half to one inch long. R1 had a
bruise approximately 3-4 inches around the laceration, in various stages of healing.
On 5/14/25 at 10:35 AM, V5 stated R1 will put her feet on the ground when R1 is at the table. (R1)
sometimes will put her feet down when you are trying to push her in her wheelchair. (R1) did it this morning
when we were coming down the hall to sit here (end of the hallway).
On 5/14/25 at 10:45 AM, V8 Licensed Practical Nurse (LPN) stated they were the nurse taking care of R1
when she fell. R1 was in her wheelchair waiting to be brought to the shower. V11 Certified Nursing
Assistant (CNA) went to push R1 in her wheelchair toward the shower room. R1 put her feet down to the
floor when the chair was moving forward, and R1 fell out of the wheelchair. R1 will sometimes put her feet
on the floor when you propel R1 in the wheelchair. R1 did it earlier this morning when V5 was taking R1
down the hall, and when R1 was being moved to the dining room for lunch. V8 stated We had to put R1's
legs back on the footrests. V8 stated R1 does self-propel with her feet on the unit. R1 has had the behavior
of putting her feet down on the floor when being pushed in the wheelchair as long as R1 has been on the
unit.
On 5/14/25 at 11:30 AM, V9 CNA stated they were working on 5/6/25. V9 said they heard V11 yell out for
help. When they looked R1 was on the floor. V9 stated in the past when they have pushed R1 in the
wheelchair R1 has put her feet on the floor. V9 stated R1 has done that for a long time.
(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:
145739
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
145739
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home for the Aged
800 West Oakton Street
Arlington Hts, IL 60004
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 - Minimal harm
or potential for actual harm
On 5/14/25 at 2:15 PM, V11 CNA stated they usually work night shift. V11 has taken care of R1 before, but
on night shift R1 is usually in bed. V11 stated they went to push R1 toward the shower room, R1 planted
her feet on the floor, and R1 fell forward out of the wheelchair. R1 was bleeding from a cut on her face. V11
stated they were not made aware R1 would put her feet down to the floor when being pushed in the
wheelchair.
Residents Affected - Few
R1's Fall assessment dated [DATE] showed R1 is at a moderate risk for falling.
R1's current Care Plan printed 5/14/25 showed no focus, goals, or interventions related to R1's behaviors of
noncompliance with wheelchair leg rests until 5/7/25.
The facility's Fall Prevention Policy dated 1/27/25 showed The nursing staff, in conjunction with the
attending physician, consultant pharmacist, therapy staff, and other members of multidisciplinary team, will
seek to identify and document resident risk factors for falls and establish a resident-centered falls
prevention plan based on relevant assessment information.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145739
If continuation sheet
Page 2 of 2
