Health inspection·February 27, 2025

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. Page 1 of 2 145295 145295 02/27/2025 Goldwater Care Marseilles 578 West Commercial Street Marseilles, IL 61341

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. 145295 Page 2 of 2