F 0689
Level of Harm - Minimal harm
or potential for actual harm
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 transfer a resident using a wheelchair.
Residents Affected - Few
This applies to 1 of 4 residents (R1) reviewed for accident hazards in the sample of 4.
The findings include:
On 5/18/24 at 9:20 AM, R1 stated, she was being transported from her room to the DR (dining room) on
5/13/24 by V3 (Activity Aide) in her wheelchair, to go for Bingo. R1 stated, she felt her wheelchair was not
moving smoothly and she toppled over and fell to the ground. R1 stated, she hit her head and it was
bleeding. There was a pair of foot pedals for wheelchair in the room. R1 stated, the foot-pedals are never
put on her wheelchair. R1 stated, she usually propels herself and sometimes, the staff helps her.
On 5/18/24 at 11:45 AM, V6 (Maintenance Director) stated, he saw R1's foot caught in the front wheel of
the wheelchair and then R1 tipped forward and fell to the floor. V6 stated, after R1's fall, he checked the
wheelchair and there was nothing wrong with the wheels or the break of the wheelchair.
On 5/18/24 at 11:55 AM, V3 (Activity Aide) stated, she was transporting R1 in her wheelchair from her room
to the DR on 5/13/24 around 2:00 PM. V3 stated, the wheelchair did not have foot pedals, so she asked R1
to hold her feet up. V3 stated, she did not see that R1 put her foot down and her foot got caught under the
front wheel of the wheelchair and she fell forward. V3 stated, she called the nurse, who assessed R1, and
sent her out to the ER (Emergency room).
On 5/18/24 at 12:20 PM, V8 (CNA-Certified Nursing Assistant) stated, while transporting residents in their
wheelchairs to avoid falls, either residents must hold their feet up or use foot pedals so that their feet does
not get caught in the wheels. V8 stated, it is the responsibility of the transporter to ensure that the resident
is holding their feet up and is safe.
On 5/18/24 at 1:45 PM, V4 (LPN-Licensed Practical Nurse) stated, while transporting residents in their
wheelchairs to avoid falls, either residents must hold their feet up or use foot pedals so that their feet does
not get caught in the wheels.
On 5/18/24 at 1:11 PM, V2 (DON-Director of Nursing) stated, when residents are being transported by staff
in their wheelchair, either use the foot pedals or ask the resident to hold their feet up. V2 stated, it is the
responsibility of the transporter to ensure the resident's feet are not touching the floor. V2 stated, R1 was
sent to the ER via ambulance and R1 returned to the facility the same
(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:
146197
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
146197
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jennings Terrace
275 South Lasalle
Aurora, IL 60505
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
day. V2 stated, R1 had a laceration with no sutures.
Level of Harm - Minimal harm
or potential for actual harm
On 5/18/24 at 12:48 PM, V1 (Administrator) stated, she heard overhead page for nurses to come and when
she arrived at the scene, the nurses were assessing R1 and R1 was bleeding from her forehead. V1 stated,
911 was called and R1 sent to the hospital. V1 stated, R1 sustained a laceration and no sutures were
needed.
Residents Affected - Few
R1's face sheet showed R1 is admitted to the facility on [DATE]. R1's MDS (Minimum Data Set) dated
4/15/24 showed R1 had no cognitive impairment. R1's fall risk assessment dated [DATE] showed R1 is at
High Risk for Falls. R1's Progress Notes dated 5/13/24 at 4:07 PM showed, around 2:00 PM, R1's left leg
got caught in the wheelchair and R1 fell to the floor and sustained a laceration on the forehead. R1 was
sent out to the hospital. R1 returned to the facility the same day with no sutures or fracture.
Facility Policy on Assistive Devices and Equipment revised on July 2017 did not include any safety
measures to be followed while transporting residents on wheelchairs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146197
If continuation sheet
Page 2 of 2
