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 the facility failed to supervise a resident who was at risk for falls due to
history of falls and failed to put specific fall intervention in place to prevent further falls, this failure resulted
in R3 sustaining a nasal fracture and left forehead lacerations requiring stitches for 1 of 3 residents
reviewed for falls in the sample of 6.
The findings include:
R3's face sheet show R3 is 76 y/o with diagnoses that include chronic venous hypertension, kidney failure
and heart disease.
R3's fall risk assessment dated [DATE] shows R3 is HIGH risk for falls.
A Facility Reported Incident dated 3/22/24 (initial) show, At 1 pm, NOD (Nurse on duty) responded to a call
for help from the room. Resident noted lying face down on then floor with wheelchair behind her. No loss of
consciousness. Resident alert and oriented and verbally responsive. Residents states that she dropped
something on the floor and wanted to pick it up, but resident unable to recall what item. Rapid response and
911 called. Resident noted with lacerations on left eyebrow, bridge of nose, left elbow, and left foot.
Pressure applied to all areas, ice pack in place.
R3's Hospital Records dated 3/22/24 show, pt arrives (from nursing home) c/o (complaint of) fall out of
wheelchair, states she was reaching for something on the floor , reached too far, lost her balance and fell
out of w/c striking face onto floor, laceration to forehead, skin tear to left elbow .
CT scan of face results dated 3/22/24: bilateral acute nasal bone fracture. There is a laceration and small to
moderate-sized soft tissue swelling involving the left forehead . diagnoses,complex laceration of left
eyebrow, contusion of face, skin tear left elbow.
R3's Hospital discharge instructions show, you have a bilateral fractured nasal bones and laceration above
left elbow. Sutures will need to be removed in 7 days.
R3's progress notes dated 3/22/34 show, x-rays- nasal bone fracture, R3's laceration above the left eye has
6 sutures in place, sutures have to be removed in 7 days.
On 3/25/24 at 9:30 AM, R3 was in bed alert. R3 has deep dark purple bruising from the top of her forehead
to underneath both of her eyes to her nasal area. There was stitches noted above her left eyebrow. When
asked what happened, R3 said she was in her wheelchair, she thought something was on the
(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:
145923
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
145923
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Warren Barr North Shore
2773 Skokie Valley Road
Highland Park, IL 60035
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
floor so she leaned forward and fell. R3 said that was all she can remember.
Level of Harm - Actual harm
On 3/25/24 at 12:30 PM, V9 (License Practical Nurse-LPN) said she was the Nurse working last 3/22/24.
V9 (LPN) said it happened around lunch time. V9 said R3 was found facedown on the floor, her wheelchair
behind her. There was poll of blood around R3's head. R3 had fallen forward from her wheelchair. V9 said
911 was called and R3 was sent to a local hospital. V9 said R3 had a fall last month, (R3 fell out of her
wheelchair inside her room reaching for something.) V9 said R3's room is in the middle of the hallway, far
from the Nurses Station where staff usually are. R3's room cannot be seen when in the Nurses Station so
R3 cannot be supervised. V9 said there was also no device to alert staff when R3 was trying to reach too
far when in her wheelchair to prevent her from falling forward.
Residents Affected - Few
R3's fall careplan dated 2/2/24 show R3 is high risk for falls due to recent fall, poor safety awareness,
impaired balance due to disease process. She has a habit of reaching/bending down to obtain items from
the floor despite education and redirection. She requires max weight bearing assistance with bed mobility,
transfers locomotion and toileting. She is noted to experience dizziness when changing position. She
utilizes wheelchair as a primary mode of locomotion at this time.
R3's fall interventions did not address R3's behavior of reaching/bending until today, 3/25/24 when surveyor
was at the facility investigating R3's fall.
The facility policy dated 7/1/7/23 entitled Fall Occurrence show It is the policy to ensure that residents are
assessed for risk for falls, that intervention are reevaluated and revised as necessary.
On 3/25/24 at 1PM, V2 (Director of Nursing) said they will be looking for R3's room placement and ways for
R3 being monitored closer.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145923
If continuation sheet
Page 2 of 2
