The Haven of Farmer City: Improper Transfer Causes Injury - IL
On August 13, 2025, a certified nursing assistant identified in inspection records as V5 entered a resident's room at The Haven of Farmer City and told a colleague they needed to get the resident up. The colleague, V6, had prepared for a mechanical lift transfer. V6 told V5 not to lift the resident manually. The facility's own cheat sheet, its CNA communication binder, the resident's care plan since admission — all of it said the same thing: two-staff mechanical lift, no exceptions.
V5 started lifting anyway.
V6 told inspectors what happened next. V5 had already begun the transfer before V6 could stop it, so V6 helped. The resident started screaming the moment they were placed in the wheelchair. V5 ran out of the room. V6 stayed.
A licensed practical nurse, V4, was at the nurses' station or the medication cart when V5 came running to say there was an emergency. V4 walked into the room and found the resident sitting upright in a wheelchair, screaming. "It hurts, it hurts, don't touch it." The resident pointed to their right shoulder and wouldn't let V4 get close enough to assess the injury. The resident was sent to the emergency department.
V4 later told inspectors that V5 had been explicit about the decision. The sling was there. V5 knew it. According to V4, V5 said they "weren't going to use that, we don't have time."
The facility's Director of Physical Therapy confirmed to inspectors that the resident had been designated a two-staff mechanical lift transfer since admission, and that the therapy department's recommendations go directly to nursing to update the care plan. "There is a reason they are a mechanical lift transfer," the director said. A stand-and-pivot transfer, or any manual transfer, was never an acceptable option for this resident.
The inspection, conducted August 22, 2025, was triggered by a complaint. Federal inspectors classified the violation under F0689, which covers accidents and supervision failures, and rated it as causing actual harm to a resident.
What makes V6's account striking is how clearly it shows the system working until the moment it didn't. V6 had the sling in place. V6 told V5 to stop. V6 cited the cheat sheet the facility's own assistant director of nursing had created for exactly this purpose. V6 said afterward: "I didn't feel the transfer was proper or correct." V6 went by the book. V5 didn't, and V6 helped anyway.
The facility's assistant director of nursing told inspectors that transfer competency training is done at hire and annually, and that staff are given a written list of each resident's transfer requirements. The system for communicating that information existed and was functioning. The CNA communication binder had the right answer in it. V6 knew the right answer. V5 knew the right answer too, and said so implicitly when acknowledging the sling was there.
The Haven reported taking immediate corrective steps on the same day as the incident. The Director of Nursing held an in-service for nursing staff on transfer procedures that evening. Audits of resident transfers were scheduled four times a week for four weeks. The facility's Quality Assurance committee convened and developed a plan of correction. The facility listed its date of substantial compliance as August 14, 2025 — the day after the resident was hurt.
The resident went to the hospital, was evaluated and treated, and returned to the facility.
What the inspection report doesn't say is what the emergency department found in that right shoulder, or what the resident's life looked like in the days after returning. It records the screaming, the refusal to be touched, the arm that hit the chair on the way down. It records a CNA who ran out of the room and a colleague who stayed. It records a seven-word explanation for why the lift was skipped.
We don't have time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Haven of Farmer City from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
THE HAVEN OF FARMER CITY in FARMER CITY, IL was cited for violations during a health inspection on August 22, 2025.
The colleague, V6, had prepared for a mechanical lift transfer.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.