Health inspection·September 4, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review the facility failed to notify R1's physician of new-onset neck pain following a fall from a hoist mechanical lift. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: R1's admission Record (Face Sheet) showed an original admission date of 1/31/23 with diagnoses to include partial left and right leg amputation; type 2 diabetes; and mild cognitive impairment. R1's 8/6/24 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. On 9/3/24 at 9:05 AM, R1 stated she had a fall a few weeks prior; however, R1 was unable to recall the details of the fall. R1 stated soon after the fall she began experiencing neck pain. R1 stated it took at least a week before she was sent out for X-rays following her fall. R1 stated she believed the facility should have notified her provider of the neck pain sooner than they did. R1's Serious Injury Incident Report submitted on 8/21/24 showed, CNA (Certified Nursing Assistant) report (V3) 8/12/24 - When transferring resident to the chair from bed with mechanical lift, resident leaned too far to the left and started to slip out. This CNA tried to brace the fall, but she still fell down .physician (V6 R1's physician) here to assess resident, 8/21/24, ordered x-ray at [local area hospital] hospital confirmed fx (fracture) of neck . R1's 8/13/22 Incident Note from 3:22 AM showed, .Resident states her neck was stiff. PRN (As needed) pain medication administered with HS (evening) pills. (Pills administered the evening of 8/12/24) . On 9/3/24 at 1:06 PM, V3 CNA stated herself and V9 CNA were transferring R1 from the bed to her geri-chair (a high back reclining chair) on 8/12/24. V3 stated she was monitoring/handling R1 during the transfer and V9 was operating the hoist mechanical lift. V3 said R1 was partially suspended over the seat of her geri-chair and as she (V3) pulled R1 towards the back of the chair R1 fell out the left side sling and hit her head, neck, and shoulder on the floor. V3 said R1 began complaining of neck pain the following day (8/13/24). On 9/3/24 at 11:30 AM, V9 CNA stated she was controlling the hoist mechanical lift for R1 on 8/12/24. V9 said she did not work with R1 for a couple of days after the fall. V9 said the next time she worked with R1, R1 was complaining of neck pain with movement. (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 4 Event ID: 146140 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 146140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Galena Stauss Nursing Home 215 Summit Street Galena, IL 61036 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)