Health inspection·February 13, 2026

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to transfer a resident safely with a mechanical lift. This failure resulted in a resident sustaining an 8 cm (centimeter) laceration, requiring 11 sutures.This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in a sample of 3.The findings include:On 2/11/26 at 10:21, V4 (CNA/Certified Nurse Assistant) said she transferred R1 from his wheelchair to his bed with mechanical lift by herself on 1/15/26 when he sustained a skin tear. V4 said R1 has always had extreme anxiety with patient care and he freaks out when he is transferred with mechanical lift. V4 said, I am thinking maybe when I transferred him, from him freaking out and shaking, he might have bumped his leg on the bed at that point. V4 said she was taught there should be two staff when transferring a resident with a mechanical lift, but she did it by herself because she thought R1 was so light and easy to do. V4 said there should always be two staff for safety precautions when transferring a resident with a mechanical lift; one staff member is supposed to control the remote, and the other staff member focuses on the resident and positioning their body during transfer.The Facility Reported Incident Final Report done by V2 (DON/Director of Nursing) dated 1/23/26 states, [R1] has very fragile skin.On 1/15/26, [V4] was transferring [R1] from his wheelchair to his bed and [V4] discovered [R1] inadvertently acquired a skin tear. [R1] was sent to the ER (Emergency Room) for further evaluation and treatment per physician's orders. Facility nurse called for an update and was notified the skin tear required sutures.R1's ER Physician Report dated 1/15/26 states, R1 has an 8 cm left leg laceration.wound closure was performed with 11 sutures after local anesthesia.On 2/11/26 between 1:30 PM-3:40 PM, V2 (DON), V3 (ADON/Assistant Director of Nursing), V9 (Restorative/Quality Assurance Nurse), V5 and V6 (LPNs/Licensed Practical Nurse), and V7 and V8 (CNAs) said when transferring with mechanical lifts, two staff are required to ensure resident's safety. V9 (Restorative Nurse) said one staff member works the lift remote, and the other staff member is there to support the resident and prevent them from bumping into anything. V8 (CNA) said many of the residents have fragile skin and one staff cannot do the mechanical lift transfer by themselves because there are too many risks of resident injury.On 2/11/26 at 4:02 PM, V10 (Mechanical Lift Customer Service Representative) said two caregivers are required to safely operate a mechanical lift for patient transfers; one person operates the lift and the second person guides the patient.R1's Face Sheet shows he has the following diagnoses: muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, chronic heart failure, peripheral vascular disease, osteoarthritis, end stage renal disease, and a history of falling. R1's MDS (Minimum Data Set) dated 1/6/26 shows he is completely dependent on the assistance of 2 or more helpers to transfer to/from chair/bed. R1's Nursing Progress Note dated 1/15/26 at 2:23 PM states, The CNA was transferring the resident from the wheelchair to the bed. In the process, the resident hit the. lower leg on the bed and had an open laceration that measures about 7cm long.the NP (Nurse Practitioner) ordered the resident to be sent out for evaluation. R1's Restorative Assessment documented on 1/5/26 Page 1 of 2 145221 145221 02/13/2026 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0689 Level of Harm - Actual harm Residents Affected - Few shows he is fully dependent on staff for chair/bed-to chair transfer and he uses mechanical lift.The facility's undated policy titled, Limited Lifting Resident Handling Policy states, Purpose: To protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents. Responsibility: Licensed Nurse, CNA, Restorative, Therapy Policy: 1. Mechanical lifting devices shall be used for any resident needing a two person assist. 145221 Page 2 of 2