Heartland Nursing & Rehab

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 observation, interview and record review the facility failed to properly transfer a resident (R3), for one of three residents (R3) reviewed for falls in a sample list of ten.

Findings include:On 10/20/25 at 10:10 AM R3 was sitting on a full mechanical lift sling in her wheelchair. R3 stated R3 fell during a staff assisted transfer in July 2025 that resulted in right leg fracture. R3 stated since then R3 has received therapy, R3 can't use her legs to walk so she transfers with a full mechanical lift. R3 stated yesterday the full mechanical lift wasn't working so the Certified Nursing Assistant (CNA), V7, used the sit to stand mechanical lift to transfer R3 from the wheelchair into bed. R3 stated during the transfer, R3 said Dear Jesus please don't let me fall.

R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact and is dependent on staff for transfers. R3's active diagnosis list includes nondisplaced comminuted fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing as of 7/23/25.R3's active Care Plan includes an intervention dated 10/16/25 TRANSFER: The resident (R3) requires Mechanical Aid Sling, (full mechanical lift) for transfers. PT/OT (physical/occupational therapy) is working with resident (R3) and this may change with their recommendation.On 10/20/25 at 10:56 AM V7 CNA confirmed V7 worked on R3's hall on 10/19/25. V7 stated sometimes one of the full mechanical lifts doesn't work and yesterday the lift on R3's hallway wouldn't go up. V7 stated V7 put in a work order request, but maintenance staff aren't in the facility on Sundays. V7 confirmed V7 used a sit to stand lift to transfer R3 on 10/19/25. V7 confirmed R3 transfers with full mechanical lift. V7 stated therapy staff have been working with R3 on two assist transfers to the commode.On 10/20/25 at 11:34 AM V13 Physical Therapy Assistant/Director of Rehab stated R3 continues on PT/OT and transfers with contact guard and minimal assist for stand pivot transfers in therapy.

V13 stated floor staff should use a full mechanical lift for R3's transfers and R3 has not been approved to use the sit to stand lift.On 10/10/25 at 12:10 PM V8 MDS/Care Plan Coordinator confirmed R3's current transfer status is full mechanical lift and may adjust per therapy recommendation. V8 stated V8 needs to check with therapy on R3's transfer status since therapy staff have been working with R3 to stand and use the commode. V8 stated V8 has not received any recommendations from therapy to change R3's transfer status.

The facility's Safe Lifting, Transferring and Movement of Residents policy dated July 2017 documents nursing staff and rehabilitation staff shall in conjunction assess each resident's needs for transfers assistance on an ongoing basis, and resident transfer needs will be documented in the care plan.

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Heartland Nursing & Rehab

410 Northwest Third Casey, IL 62420

SUMMARY STATEMENT OF DEFICIENCIES