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
Based on observation, interview and record review, facility staff failed to operate the facility van, with a
resident aboard, in a safe manner to prevent an accident, for one of three residents (R1), reviewed for
accidents. This failure resulted in R1 sustaining a nondisplaced fracture of the left patella, unspecified
fracture.
Findings include:
The facility's Vehicle Safety Program policy, undated, documents that while driving will never be a risk-free
activity, the goal of a vehicle safety program is to promote a heightened level.
of safety awareness and responsible driving behaviors to protect employees, customers, and the general
public from unsafe vehicle operations. For organizations that employ workers to operate a company vehicle
or their personal vehicle while performing company-related duties, establishing a comprehensive vehicle
safety policy will emphasize the organization ' s commitment to safe vehicle operations.
On 2/25/25 at 9:30am, R1 stated that he was going to an appointment in the facility van, there was an
accident. R1 stated that V4, Dietary Manager, was driving the van, not the regular driver. R1 stated that
entering the parking garage and the top of the van hit the ceiling or something of the parking garage. R1
stated that he was jerked forward and hit the seat in front of him. R1 stated that he was having a lot of pain
in his left knee area. R1 stated that the fire department and ambulance got him to a gurney and took him to
the emergency room. R1 stated that he was told he had a fracture in his knee but has to go for further
testing to determine the extent of the injury. V9, Registered Nurse, applied R1's left knee brace. R1's left
knee was swollen, and slight bruising was observed. R1 complained of increase pain with movement.
On 2/25/25 at 10:30am, V4 stated that she did receive a demonstration on to how to use and drive the van,
but not a safety course. V4 stated she only transports only when she has too. V4 stated that there was a
parking garage next to the building they were going. V4 stated that there was a slight incline to enter the
garage, so she gave the van some gas to enter and hit something. V4 verified that she hit the sign
indicating the height clearance of the parking garage. V4 verified that she did not even think about the
height difference. V4 stated that she put the van in park and called 911. V4 stated that R1 slid forward in the
wheelchair and hit his knees on the seat in front of him. V4 stated that R1 was complaining of increase pain
in his left knee area. V4 stated that the ambulance assisted R1 out of the van, then onto a gurney. V4
verified that R1 was taken to the emergency room. V4 stated that R1 never fell out of his wheelchair and
was seat belted in during the incident.
(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:
145295
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
145295
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Marseilles
578 West Commercial Street
Marseilles, IL 61341
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
R1's emergency room notes, dated 2/14/25, documents that the reason for visit is a motor vehicle accident.
R1's left knee x-ray documents that R1 sustained a cortical disruption involving the cortex along the
anterior margin a patellar spur at the patellar tendon. This form documents that R1 was treated for a
nondisplaced fracture of the left patella, unspecified fracture morphology. R1's physician orders include
instructions for the care of a patella fracture and to follow-up with an orthopedic physician.
V14's, Police Officer, accident report, dated 2/14/25 at 1:26pm, documents that (V4) turned left into the
parking garage and attempted to enter it. (V4) pulled into this parking garage, the front end of its roof
collided with the clearance sign which is connected to the involved parking garage. When the collision
happened (R1) rolled forward and bumped his left knee against the backside of the seat. It should be noted,
this passenger was sat in a wheelchair at the time of the collision and occupants reported the seatbelt to be
properly fastened.
On 2/26/25 at 2:00pm, V2, Director of Nursing, stated that the facility has a check list to be completed for
the facility van driver qualifications.
On 2/27/25 at 10:40am, V14, Police Officer, stated that he did not see R1 on site, he was already being
taken to the emergency room. V14 stated that the ambulance personnel told him that R1 slid down in the
wheelchair with his butt half off the chair. V14 stated that V4 hit the actual height clearance sign of the
parking garage. V14 stated that facility vans height clearance is located in front of the steering wheel, in
clear view.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145295
If continuation sheet
Page 2 of 2
