The Haven Of Farmer City
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
stated staff (V5 and V6 CNAs) did not use a mechanical lift to transfer Resident R1. Resident R4 stated, they dropped [Resident R1] in [Resident R1's] wheelchair and [Resident R1] hit arm on chair. On 8/22/25 at 11:13am, V6 (CNA) stated on the date of the incident (8/13/25) V6 had mechanical lift sling underneath Resident R1 and the mechanical lift in the room ready to hook Resident R1 up to the mechanical lift. V6 stated, [V5 CNA] entered the room and said 'we need to get [Resident R1] up.
Can you lift?' V6 stated V6 advised V5 not to lift Resident R1, we have mechanical lift and need to be doing it the proper way. V6 stated V5 already started lifting Resident R1 and V6 then assisted. V6 stated Resident R1 started screaming immediately once in chair. V6 stated V5 ran out of the room at that time and V6 stayed with Resident R1. V6 stated V4 (Licensed Practical Nurse) came into the room to assess Resident R1 and Resident R1 was sent out to the emergency department. V6 stated, I didn't feel the transfer was proper or correct. V6 stated V6 went by what the CNA communication book stated for resident transfer status. V6 stated V7 (Assistant Director of Nursing/ADON) made a cheat sheet for staff to use that listed resident transfer status. On 8/22/25 at 11:35am, V9 (Director of Physical Therapy) stated after a resident is screened for their transfer status, the recommendations are given to the nursing department who updates residents care plan with the appropriate transfer status. V9 stated if a resident is a mechanical lift transfer, the lift should be done with two staff, and the resident should never get transferred any other way especially a stand and pivot. V9 stated there is a reason they are a mechanical lift transfer. V9 confirmed Resident R1 is a two staff assist mechanical lift transfer.On 8/22/25 at 11:47am, V4 (LPN) stated on the date of the incident (8/13/25) V4 was either at the nurses' station or the medication cart when V5 approached claiming V4 need to come to Resident R1's room due to an emergency. V4 stated when V4 entered Resident R1's room, Resident R1 was sitting upright in Resident R1's wheelchair screaming, it hurts, it hurts, don't touch it. V4 stated V4 asked Resident R1 what hurts and Resident R1 stated my right shoulder. V4 stated Resident R1 would not let V4 assess Resident R1. V4 stated Resident R1 was sent out to the emergency department at that time for evaluation and treatment. V4 stated both V5 and V6 admitted to transferring Resident R1 without a mechanical lift. V4 stated V6 was ready to go with the mechanical lift and the mechanical lift sling was present under Resident R1. V4 stated, [V5 stated] ‘they weren't going to use that (sling), we don't have time.' V4 stated staff are aware Resident R1 is a mechanical lift transfer and has been since admission to the facility. On 8/22/25 at 11:01am, V7 (ADON) stated nursing staff have transfer competency done upon hire and yearly. V7 stated nursing staff are provided a cheat sheet with resident transfer status listed on it and it is documented in the CNA communication binder. Prior to the survey date of 8/22/25, the facility had taken the following actions to correct the non-compliance: 1. On 8/13/25, Resident R1 was sent to the hospital for evaluation and treatment and then returned to the community.2. On 8/13/25, the Quality Assurance Committee developed a Plan of Correction for the 8/13/25 incident and a Performance Improvement Plan.3. On 8/13/25, the Director of Nursing provided in-service education to nursing staff on the transfer policy, following individualized transfer procedures, baseline care plans and how to communicate ADL needs of residents.4. Starting on 8/13/25,
the Director of Nursing will audit resident transfers four times a week for four weeks to ensure staff are appropriately transferring.5. Starting on 8/13/25, the Director of Nursing will audit resident charts for current transfer status in baseline and/or comprehensive care plan four times a week for four weeks.6. The facility QAPI Committee will continue to monitor the facility's performance to ensure corrective actions to the 8/13/25 incident is effective.7. Completion date of substantial compliance: 8/14/25.
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THE HAVEN OF FARMER CITY in FARMER CITY, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FARMER CITY, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE HAVEN OF FARMER CITY or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.