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 provide adequate supervision/assistance when
ambulating a resident to prevent a fall for one of four residents (R2) reviewed for accidents in the sample list
of four residents. This failure resulted in R2 falling and suffering a fractured humerus when staff stepped
away from R2 to untangle oxygen tubing.
Findings include:
The Care Plan dated 4/1/25 documents R2 was admitted to the facility on [DATE].
The Care Plan dated 4/1/25 documents R2 was admitted with the following diagnosis: systolic (congestive)
heart failure, type 2 diabetes mellitus with unspecified complications, chronic gout, morbid (severe) obesity
due to excess calories, polyneuropathy, dependence on renal dialysis, end stage renal disease, cellulitis of
left lower limb, cellulitis of right lower limb, type 2 diabetes mellitus with diabetic nephropathy, hypertensive
heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage
renal disease, dyspnea, muscle wasting and atrophy, multiple sites, unsteadiness on feet, and other lack of
coordination.
The Nurses Progress Notes dated 2/28/2025 at 2:40 PM document R2 was walking with therapy with the
walker as the therapist trailed behind with the wheelchair. The therapist was attempting to adjust the oxygen
tubing when the resident had some weakness and lost balance. The Note documents R2 complained of
right shoulder pain and was unable to perform range of motion. R2 was subsequently sent to the local
emergency room.
On 4/1/25 at 2:07 PM V3, Physical Therapy Aide, stated that V3 was ambulating R2 in the hallway. V3
stated R2 was using a walker for ambulation, when R2's oxygen tubing became tangled around the
wheelchair that was being pulled behind R2 during ambulation. V3 stated V3 bent over to untangle the
tubing and R2 fell forward landing on the floor.
On 4/1/25 at 2:07 PM V3, Physical therapy aide, demonstrated being behind the wheelchair bent over to
untangle the oxygen tubing and unable to reach R2 due to the gap between V3 and R2.
The Physical Therapy Progress Note dated 2/28/2025 at 4:20 PM documents R2 as requiring CGA
(Contact Guard Assist) for ambulation with recovery breaks in between each set. The Note documents R2
notes increase in fatigue and SOB (Shortness ff Breath). R2 fell this session, while standing, R2's oxygen
tube was caught on the wheelchair. While dislodging the tube R2 fell forward and has an abrasion on her
right knee, elbow and cheek bone notified nursing of the accident.
(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:
145965
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
145965
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab of Decatur
500 West McKinley Avenue
Decatur, IL 62526
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
Residents Affected - Few
On 4/2/25 the NIH (National Institute of Health) Web Site defines Contact Guard Assist as the caregiver
places one or two hands on the patient's body to help with balance but provides no other assistance to
perform the functional mobility task. https://www.ncbi.nlm.nih.gov.
Hospital Records dated 2/28/25 at 4:18 PM document R2 arrived at the hospital with a Chief Complaint of
fall while doing physical therapy and that R2 reports right shoulder pain and states she hit her face as well.
Hospital Records dated 2/28/25 at 6:17 PM document R2 was diagnosed with a closed comminuted
fracture of the right humerus, facial contusion, multiple abrasions and right elbow pain.
On 3/31/25 at 11:24 AM V5, R2's Family, confirmed that R2 was admitted to the hospital for a fractured
right humerus and needed surgical repair.
On 4/1/25 at 10:00 AM V1 confirmed that V3 was ambulating R2 in the hallway by himself with a walker
while trailing R2 with a wheelchair that was carrying R2's oxygen on the back of the wheelchair.
On 4/1/25 at 10:40 AM V9, Director of Rehabilitation, confirmed V3 was ambulating R2 in the hallway by
himself with a walker while trailing R2 with a wheelchair that was carrying R2's oxygen tank on the back of
the wheelchair. V9 confirmed V3 was behind the wheelchair and not in reach of R2 or the gait belt around
R2. V9 confirmed two staff members will be used to ambulate residents with multiple pieces of equipment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145965
If continuation sheet
Page 2 of 2
