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
interview, record review, and observation the facility failed to provide supervision to prevent falls for 1 of 14
resident (R5) reviewed for falls in the sample of 33.
Findings Include:
On 10/26/23 at 11:48 AM V17, Certified Nurse's Aide, CNA assisted R5 with transferring R5 from the bed
to the wheelchair and then from the chair back to bed with gait belt.
R5's Face Sheet, undated, documents R5's has diagnoses of unspecified dementia, repeated falls, and
fracture of unspecified part of neck of left femur,
R5's Minimum Data Set (MDS) dated [DATE] documents R5 is a limited assistance of one staff for
transfers. R5's MDS documented that R5's balance was not steady only able to stabilize with staff
assistance for going from seated to standing and moving on and off the toilet. The MDS documented R5
required one-person physical assistance with transfers and toileting. The MDS also documents R5 is
severely cognitively impaired.
R5's Fall Risk Acuity form dated 6/8/23 documents that R5 is not high risk for falls.
R5's Incident/Accident report, dated 7/16/23, at 4:45 PM, documented resident found on floor @ (at) foot of
bed, legs extended towards doorway on her back. The Report documented cont. (continue) visual check.
Resident not left unattended in restroom.
R5's Nurse's Noted dated 7/16/23 documents at approximately 4:45 PM. This nurse was in hallway
providing care for other residents during a code yellow alert, resident roommate noted to be shouting for
help. this writer and 2 Certified Nursing Assistants (CNA) went to room immediately. Resident (R5) was
found lying on her back with (BLE) bilateral lower extremities extended outward towards the door and head
near her footboard. Resident (R5) reported she had gotten herself out of the bathroom since she knew
everyone was busy. Resident assessed for injury. ROM WNL (Range of Motion Within Normal Limits). able
to bend at bilateral knee and ankles, reports pain to left knee. neuro assessment WNL. denies hitting head
on floor, reports she went down sideways onto her knee and side. neurological assessment continues. grips
equal, pupils equal and light reactive. VSS (Vital Signs) 98.7 (temperature)-98 (pulse)-22
(respiration)-145/89 (blood pressure)-98% (oxygen saturation level) RA (room air). Resident presents very
restless pertaining to fall. Assisted back upright to wheelchair with 2 staff assist. tolerated OK, able to bear
weight with complaints of pain. later transfers to toilets with one assist via pivot transfer with complaints.
The Note documented that R5's medical doctor (MD)
(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:
145445
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
145445
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accolade Healthcare of Waterloo
623 Hamacher Street
Waterloo, IL 62298
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
was notified and ordered a Xray of left knee.
Level of Harm - Minimal harm
or potential for actual harm
R5's Nurse's Note dated 7/16/23 at 8:15 PM documented staff & (and) resident education provided,
resident not to be left unattended in restroom. resident education provided on call light use, safety
precautions, proper body mechanics to prevent injuries. increased visual checks and monitoring to
continue.
Residents Affected - Few
R5's Radiology Report dated 7/16/23 documents an Acute Distal Diametaphyseal Fracture.
R5's Nurse's Note dated 7/17/23 documents R5 had an acute distal diametaphyseal fracture of left femur.
R5's Nurse's Note, dated 7/17/23 at 11:10 AM, documented that MD wanted R5 sent to emergency room to
treat fracture.
Care Plan dated 10/24/23 documents Problem: Increased susceptibility to falling that may cause physical
harm R/T (related to) H/O (history of) frequent falls, age related debility, uses of assistive device (walker,
cane), visual/hearing difficulties, incontinence, impaired physical mobility, poor safety awareness, poor
insight into deficits. 5/3/20 fall in bedroom, no injury. 5/28/20 fall in room, no injury. 7/16/23 fall in bedroom,
fractured L femur. Fall Interventions are toileting every 2 hours, staff to make frequent checks while she is in
her room, shoes or nonskid socks, review medication regimen.
On 10/27/23 at 11:00 AM V2 Director of Nursing (DON) stated We placed her on the toilet, and then we had
a code yellow. She (R5) thought we were busy and tried to put herself to bed.
On 10/27/23 at 11:30 AM V30, Certified Nurse's Aide, CNA stated, I remember someone yelling for help. A
group of us ran to the room. She (R5) was on the floor in front of the wheelchair. She was either coming out
or going into the bathroom. We work together on that hall. I didn't place her on the toilet.
On 10/27/23 at 11:48 AM V29, Nurse Practitioner, so the hard part of this I didn't assume care until after
this fall. In general, it would depend on if the patient could put on the call light when they are done. You
would expect them to pull the light.
The facility policy Fall Prevention Program, dated 9/16/22, documents each resident will be assessed for fall
risk and will receive care and services in accordance with their individualized level of risk to minimize the
likelihood of falls.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145445
If continuation sheet
Page 2 of 2
