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, the facility failed to supervise a resident (R5) with a
metastatic brain neoplasm and prevent an injury for one (R2) of two residents reviewed for accidents in a
sample of five. This deficiency resulted in R2 going to the hospital, sustaining a fracture to his right knee,
and ongoing pain requiring pain medication.
Findings include.
Facility's Residents' Rights for People in Long Term Care Facilities, Ombudsman Program revised 11/2018,
documents: Your facility must treat you with dignity and respect and must care for you in a manner that
promotes your quality of life. Your facility must provide services to keep your physical and mental health, at
their highest practical levels.
Facility Abuse Investigation Report, dated 2/12/25, documents (R5) went into (R2's) room and threw a chair
at (R2) while (R2) was in bed. (R2) complained of right knee pain and sent to the hospital for assessment.
Pain medication was administered to (R2).
R2's Medication Administration Record/MAR, dated 2/1-2/12/25, documents R2 was taking Tylenol
650mg/milligrams four times a day for pain.
R2's MAR, dated 2/12-2/28/25 and 3/1-3/4/25, documents R2 was ordered Norco 5-325mg take one tablet
every 24 hours taken 2/18/25 for pain 5/10 and 2/19/25 for pain 7/10. Norco 5-325mg 1 tablet every eight
hours as needed for right knee pain taken 2/12 for pain 4/10; 2/13 for pain 6/10; 2/17 for pain 7/10;
2/20-2/22 for pain 8/10; 2/24 for pain 6/10; 2/28 for pain 7/10; 3/1 for pain 7/10; and 3/3 for pain 8/10.
R2's medical record documents the following: (R2's) progress note by (V9 APRN/Advanced Practice
Registered Nurse), dated 2/12/25, documents Patient seen today for follow up on uncontrolled right lower
extremity pain. pain in right knee new onset status post injury where he was hit with a chair.
R2's after visit summary from the hospital (2/13-2/17/25) progress note by V10 MD/Medical Doctor, dated
2/13/25, documents (R2) states he is having pain in his knee.
R2's cat scan from the hospital, dated 2/14/25, documents Acute mildly displaced and mildly impacted
fracture of the lateral femoral condyle posterior aspect with possible extension into the intercondylar notch.
Prepatellar soft tissue swelling. (R2's prior x-ray from 2/11/25 documents R2 has no fracture.)
(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
03/05/2025
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
R2's orthopedic consultation note by V11 MD, dated 2/15/25, documents Orthopedic consultation for a right
distal femur fracture. (R2) was attacked by a roommate and began reporting knee pain. Recommendations:
Non-operative management and pain control.
R2's medical record documents the following: (R2's) progress note by V9 APRN, dated 2/19/25, documents
Patient seen today in the facility and then again via telehealth this evening around 10:30PM for RLE/right
lower extremity pain. Patient rates pain to RLE an 8/10. He is requesting a Norco; however, Norco is
currently ordered q24 hours prn/as needed. Previous order was every 8 hours prn. Patient has new
LE/lower extremity femur fx/fracture. Mild distress. Upset with inability to receive additional pain medication
due to uncontrolled pain. I ordered Norco every eight hours as needed. Pain in right knee is a new onset s/p
(status post) injury where he was hit with a chair. X-ray in ER/emergency room was negative, repeat x-ray
negative, and then Femur fracture diagnosed in the hospital.
On 3/4/25 at 11:30AM, R2 stated I have to rest my right knee due to (R5) throwing a chair at me. My knee
is fractured, and I take pain medication for it, I can't do physical therapy or wear my prosthesis. I had an
X-ray here (nursing home,) the hospital, and then another hospital.
On 3/4/25 at 1:50PM, V2 DON/Director of Nursing stated (R5) threw a chair at (R2), and (R2) went to the
hospital.
On 3/4/25 at 2:15PM, V1 Administrator stated, I heard (R2) had a fracture.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145295
If continuation sheet
Page 2 of 2
