Health inspection·September 21, 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 ensure a resident was safely transferred with a full mechanical lift according to their plan of care for 1 of 3 residents reviewed for safety/supervision in the sample of 5.The findings include:R2's electronic face sheet printed on [DATE] showed R2 has diagnoses including but not limited to congestive heart failure, morbid obesity, muscle weakness, and muscle wasting.R2's facility assessment dated [DATE] showed R2 has no cognitive impairment and is dependent on staff for transfers.R2's care plan dated [DATE] showed, The resident has an ADL (Activities of Daily Living) self-care performance deficit related to weakness, balance/endurance deficit .the resident requires mechanical lift with 2 staff assist for transfers.On [DATE] at 10:40AM, R2 stated, The first I had an issue with (V3-Certified Nursing Assistant-CNA) taking care of me was about 2 months ago. The (full body mechanical lift) wasn't working right or the battery was dead or something and it quit working and she wanted to sit me on the edge of the bed and she was going to lift under my arms and drop me in the chair. She picked me up under my arms and the other girl was behind me.There were 2 aides in here I just can't remember who the other one was. She scares me when she transfers me because she's not nice about it and she shouldn't be transferring me without the lift. They told me I need the lift at all times. That's the only way I feel safe.On [DATE] at 12:14PM, V3 stated, This incident was a few months ago. (R2) had her call light on in her wheelchair to use the bathroom. The (full body mechanical lift) was dying but we had enough battery to get her to bed. As we were getting her on the bed the (full body mechanical lift) died and we got her positioned onto the bed pan. We told her to wait a few minutes so we could charge it for about 15 minutes. We got her off the bed pan and there wasn't enough charge on the lift. We asked (V2-Director of Nursing) if we could do a 2 person transfer for her and he said it was fine. We do transfers like this all the time. I put the gait belt around her and (V2) was behind her. We put her in the wheelchair and it was just fine. There were a lot of people using the lifts that day so that's why it must have been dead.(V4-CNA) was the other aide in there. If I thought it was wrong or would have hurt her I never would have done it. I have seen people use a stand lift for her so I didn't really think it was much different.On [DATE] at 12:30PM, V4 stated, The transfer for (R2) was me and (V3) and we did it from the chair to the bed and she just kind of did the pivot transfer. I guided her hips onto the bed but didn't do much more. (V3) just grabbed her under her arms and got her to the bed that way. We didn't have any problems that day but her ability to bear weight isn't consistent. They have tried a stand lift with her but she was crying. (V2) was never even in the room or part of the conversation so I'm not sure why (V3) is saying that she got permission from him.On [DATE] at 12:54PM, V2 stated, I was not in the room at all during the transfer of (R2) nor did I have any knowledge that there was an issue with the lifts that day. They didn't ask me anything about transferring her without the (full body mechanical) lift.I honestly have no idea what they are talking about and I was never (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: 145950 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 145950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Generations at Rock Island 2545 24th Street Rock Island, IL 61201 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)