Health inspection·March 29, 2025

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 and record review the facility failed to prevent a fall for one resident (R2) of 3 residents reviewed for transfers in the sample of 3. Finding include: The Lifting Machine, Using a Mechanical Lift policy dated 7/2017 documents Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift device. It is not a substitute for manufacturers training or instructions. General Guidelines: 1. At least 2 (two) nursing assistants are needed to safely move a resident with a mechanical lift. R2's Face Sheet documents R2 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease, Chronic Kidney Disease Stage 4, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Cerebral Infarction, Transient Cerebral Ischemic Attack, Varicose Veins of Left Lower Extremity with Ulcer of Unspecified Site, Chronic Diastolic Heart Failure, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Vitamin Deficiency. R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2's Brief Interview for Mental Status/BIMS is 15 (cognition intact). R2 uses a wheelchair and is dependent for transfers. R2's Nursing Note written by V6 (Licensed Practical Nurse/LPN) dated 3/4/25 at 12:00 PM, documents This Nurse was informed at 11:00 AM (R2) had slid on the floor from her wheelchair. CNA (Certified Nursing Assistant) stated resident was not all the way back in her wheelchair and slid to the floor. Upon arrival resident was sitting on her buttocks. No injuries noted. R2's Fall Investigation written by V1 (Administrator) dated 3/4/25 documents that at approximately 10:45 AM V1 was notified that R2 had been involved in a fall from a mechanical sit-to-stand lift. When V1 responded to the scene of the fall, R2 was lying on the floor in front of her wheelchair and the sit-to-stand lift was placed to the side of R2. V4 (Previous Certified Nursing Assistant/CNA) was standing behind the sit-to-stand lift, and V6 (LPN) was kneeling next to R2 performing an assessment. V1 asked V4 what had happened and V4 told V1 that as she was lifting R2 with the sit-to-stand lift, R2 slid forward out of the chair. V1 asked V4 to go to V1's office. In the office V1 asked V4 for a statement regarding R2's fall. V4 stated she was transferring R2 from R2's wheelchair to take R2 to the bathroom. V1 asked V4 who else had assisted with the transfer, and V4 replied no one helped V4 because they were all busy. (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: 145457 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 145457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quincy Healthcare & Sr Living 1440 North 10th Street Quincy, IL 62301 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)