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 ensure staff safely assisted and supervised a
resident while showering. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3.
The findings include:
R1's face sheet shows he is a [AGE] year-old male admitted to the facility on [DATE]. R1's diagnoses
including neoplasm of the brain, muscle weakness, aphasia, cognitive communication deficit, history of
falling, cerebral infarct, and unspecified convulsions.
R1's Minimum Data Set assessment dated [DATE] shows severe cognitive impairment, has limited range of
motion with impairments to one side affecting his upper and lower extremity, and dependent on staff for
showers/bathing.
On 01/07/25 at 9:49 AM, R1 was observed in a high back wheelchair located near the nurse's station in the
hallway. R1 was leaning forward and back repeatedly in his wheelchair. R1 was alert to self only. R1 said he
fell but does not recall the details of the fall.
On 01/07/25 at 9:52 AM, V3 (Registered Nurse/RN) said R1 is alert to self with right sided weakness. He
leans forward when he is in his wheelchair this is normal for him. She was R1's nurse the on 12/27/24 when
he fell in the shower room. She was notified by V4 (Certified Nursing Assistant/CNA), R1 fell in the shower
room. V4 reported while he turned away from R1 to get his clothes, R1 fell forward out of the shower chair.
R1 needs close supervision and should have two staff while showering R1.
On 01/07/25 at 10:02 AM, V5 (CNA) said R1 has right sided weakness, he transfers and showers with two
person assist. R1 is alert to self but does not answer questions appropriately or understand what you are
saying. R1 has always been a two person assist during showers because he is weak, unsteady and at risk
for falls When giving a resident a shower, staff should ensure items are within close reach.
On 01/07/25 at 11:49 AM, V4 (CNA) said he was R1's CNA on 12/27/24. He was told R1 was a two person
assist for showers, R1 was a newer admit and had not given him a shower prior. He transferred R1 from his
bed to the wheelchair and wheeled him to the shower room. R1 was not steady during the transfer from the
bed to the wheelchair. After showering R1, he turned his back away from R1 and reached for a towel and
R1's clothing placed on the shower bench against the wall. When he turned around, R1 was leaning over in
his shower chair and fell on the floor. He was cueing R1 directions to stay
(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:
146136
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
146136
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Radford Green
960 Audubon Way
Lincolnshire, IL 60069
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
Residents Affected - Few
still, but he was not sure if R1 understood him. V4 said he used a regular shower chair and did not dry off
R1 yet with the towel. V4 said he felt confident enough to give R1 a shower himself. V4 said he should have
placed the items closer in reach.
R1's current care plan shows he is at risk for falls with interventions to be assisted in shower x 2 until
reclining chair is available.
The facility's Final Investigation dated 12/28/24 documents on 12/27/24, (V4 CNA) was assisting a (R1)
with a shower. (V4) turned to grab the clothes off the other chair when (R1) leaned forward and fell to the
floor .due to weakness and trunk control resident will be assisted x 2 until a reclining shower chair is
available.
The facility's Falls Protocol undated policy states, the staff will document risk factors for falling in the
resident's record and discuss the resident's fall risk .the staff and physician will identify pertinent
interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146136
If continuation sheet
Page 2 of 2
