Health inspection·October 1, 2024

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely transfer a resident (R1) by mechanical lift from a geriatric chair to bed. This failure resulted in R1 being hit in the shoulder by the mechanical lift equipment causing a hematoma to R1's shoulder and R1's foot becoming caught in R1's geriatric chair causing a fracture. R1 is one of three residents reviewed for accidents in the sample of three. Findings include: The facility Transfers-Manual Gait Belt and Mechanical Lift Policy (revised 1/19/18) documents the following: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility will use mechanical lifting devices for the lifting and movement of residents. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. The transfer needs of residents will be assessed on an ongoing basis and designated into one of the following categories: H-Mechanical Lift with two caregivers. R1's Face Sheet dated 10/1/24 documents R1 is on Hospice and R1's diagnoses include: Alzheimer's Disease, Dementia, Hypothyroidism, Hypertension, and Pulmonary Fibrosis. R1's Medical Record does not document R1 as having any underlying bone diseases. R1's Comprehensive assessment dated [DATE] documents R1 is severely cognitively impaired with no upper or lower limb impairments, uses a wheelchair (geriatric chair) for mobility, and is dependent on staff for all activities of daily living (ADL) including transfers. R1's Care Plan (current) documents R1 has ADL self-care deficit related to impaired balance, Alzheimer's/Dementia, uses a mechanical lift for transfers and a geriatric chair for mobility. This same record documents for chair to bed/bed to chair transfers, R1 requires two staff with a mechanical lift. The facility investigation report dated 9/15/24 documents R1 was observed by the nurse (V4) exhibiting signs and symptoms of pain and decreased range of motion (ROM) to the left lower extremity. This same report documents R1 was assessed by the nurse and bruise to left shoulder was observed and V17 R1's Representative refused x-rays until 9/17/24. Further documents R1 diagnosed with a left distal femoral fracture on 9/18/24 and knee immobilizer in place. The same report documents V3 Certified Nurses Assistant (CNA) found to have improperly transferred R1 with a mechanical lift without assistance. (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: 145911 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 145911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Gibson City 620 East First Street Gibson City, IL 60936 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)