Inspection·August 21, 2024

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. Based on observation, interview, and record review the facility failed to ensure resident safety during transfer, failed to use a gait belt during resident transfer, and failed to follow the facility policy and procedure for mechanical lift slings for one (R4) of three residents reviewed for falls in a sample of four. Findings include: The facility's Fall Prevention Program policy, revised 11/21/17, documents Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Malfunctioning equipment will be immediately reported to maintenance for repair or removed from service. The facility's Transfers - Manual Gait Belt and Mechanical Lifts policy, revised 1/19/18, documents: Purpose: In order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use Mechanical lifting devices for lifting and movement of Residents .Guidelines: 4. Mechanical lift equipment shall undergo routine maintenance checks by the nursing and maintenance staff to ensure that equipment remains in good working order .9. Use of gait belt for all physical assist transfers is mandatory. 1. On 8/16/24, at 12:50 pm, V6 Certified Nursing Assistant/CNA wheeled R4 into his room. V7 CNA arrived to assist in transferring R4 from his wheelchair to the bed. They wheeled R4 next to his bed and while V7 stood beside the wheelchair, V6 had R4 stand and pivot then sit on the bed; no gait belt was used. On 8/16/24, at 2:18 pm, V6 CNA confirmed she did not place a gait belt on R4. V6 stated they do not use a gait belt on (R4) because it bothers his suprapubic catheter if they put it down too low and he says it hurts his abdomen if we put it up higher. We just have him reach and use the bedrail to get into bed and that's why we use two staff. R4's Minimum Data Set/MDS assessment, dated 7/18/24, documents R4 requires partial/moderate assistance for chair/bed-to-chair transfer. R4's current Care Plan documents R4 is at risk for fall/injury from weakness and tiredness. On 8/16/24, between 2:35 pm - 2:45 pm, V5, V8, and V9 CNAs denied ever having a problem using a (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: 145486 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 145486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Spring Valley 1300 North Greenwood Street Spring Valley, IL 61362 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)