The Haven Of Farmer City

stated staff (V5 and V6 CNAs) did not use a mechanical lift to transfer R1. R4 stated, they dropped [R1] in [R1's] wheelchair and [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 R1 and the mechanical lift in the room ready to hook R1 up to the mechanical lift. V6 stated, [V5 CNA] entered the room and said 'we need to get [R1] up.

Can you lift?' V6 stated V6 advised V5 not to lift R1, we have mechanical lift and need to be doing it the proper way. V6 stated V5 already started lifting R1 and V6 then assisted. V6 stated R1 started screaming immediately once in chair. V6 stated V5 ran out of the room at that time and V6 stayed with R1. V6 stated V4 (Licensed Practical Nurse) came into the room to assess R1 and 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 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 R1's room due to an emergency. V4 stated when V4 entered R1's room, R1 was sitting upright in R1's wheelchair screaming, it hurts, it hurts, don't touch it. V4 stated V4 asked R1 what hurts and R1 stated my right shoulder. V4 stated R1 would not let V4 assess R1. V4 stated R1 was sent out to the emergency department at that time for evaluation and treatment. V4 stated both V5 and V6 admitted to transferring R1 without a mechanical lift. V4 stated V6 was ready to go with the mechanical lift and the mechanical lift sling was present under R1. V4 stated, [V5 stated] ‘they weren't going to use that (sling), we don't have time.' V4 stated staff are aware 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, 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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