Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 ensure a resident was safely transferred, via a
mechanical lift, in a manner to prevent resident injury. This failure resulted in R1 fracturing her right
clavicle(collarbone) and right lower leg (tibia and fibia), after falling out of a mechanical lift, due to the cloth
sling of the mechanical lift becoming unhooked from the lift. This failure applies to 1 of 3 residents (R1)
reviewed for safety and supervision in the sample of 3.
The findings include:
The facility's Fall Incident report dated 1/10/24 showed staff (V4 Registered Nurse/RN and V5 Certified
Nursing Assistant/CNA) were transferring R1 from her bed to wheelchair, via a mechanical lift, when R1
moved her upper body in the lift sling which caused the sling to unhook from the lift. R1 then fell out of the
lift, onto to the floor. 911 was called. R1 was transferred by ambulance to a local hospital. V10 (Family of
R1) was in R1's room and witnessed R1's fall. The report showed prior to the transfer, R1 and V10 were
speaking loudly back and forth to each other, in their native language, as R1 was initially refusing to get out
of bed and was refusing cares offered by staff. The report also showed facility staff had to remind (R1) more
than once to keep her arms crossed over her chest and to sit still while attempting to transfer R1.
R1's hospital records dated 1/10/24 showed, Patient was being transferred by [mechanical] lift at nursing
home and fell . Patient complains of right leg pain and right shoulder pain . The records showed R1 was
diagnosed with a right clavicle (collarbone) fracture and a right tibia/fibia (lower leg) fracture as a result of
the fall.
R1's current care plan showed R1 had a history of behaviors including moderate to extreme anxiety,
refusing cares, depression, agitation, impulsive behaviors, verbal behaviors, and physical behaviors. The
care plan showed, Utilize de-escalation strategies when a resident has an episode of agitation/anxiety
behaviors . allow time alone to promote calmness .Evaluate the potential causal factors contributing to
feelings of anxiety. Work with the resident to eliminate causes whenever possible. A care plan focus area for
R1, initiated 7/23/23, showed R1 required the use of a [mechanical] lift for transfers related to her
diagnoses of anxiety, weakness, and a previous fall resulting in a right femur fracture. The care plan focus
area showed R1 had a history of moving during [mechanical] lift transfers. The plan showed, Hook sling
loops on metal hooks and pull sling down to ensure security . Prompt resident prior to lifting to ensure
readiness .
On 1/22/24 at 11:47 AM, R1 was in bed. Purple bruising was noted above R1's right eye and down R1's
right lower leg. This surveyor tried to interview R1, twice, but was unsuccessful. Although awake, R1 would
only shrug her shoulders and gave no verbal response when questioned.
(continued on next page)
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
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145304
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145304
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Elevate Care Riverwoods
3705 Deerfield Road
Riverwoods, IL 60015
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Actual harm
Residents Affected - Few
On 1/22/24 at 10:20 AM, V5 CNA stated on 1/10/24, R1 and V10 (Family of R1) were arguing and yelling at
each other because (R1) was refusing to get out of bed and go to her appointment. (R1's) face was red.
She was mad. V5 stated R1 eventually agreed to get out of bed and go to her appointment but continued to
argue with V10. V5 stated, We (V10 and V4 RN) continued to get (R1) ready. We got her up into the lift. She
was still arguing with (V10). When (R1) leaned to her left to shake her left hand at (V10), the lift sling dipped
down and the sling loop, by her left leg, came away from the lift. (R1) rolled out of the lift onto the floor. I
don't know how that happened. V10 stated for resident safety, staff are not to transfer a resident via
mechanical lift if the resident is agitated. V10 stated, (R1's) family gets her worked up a lot. Next time, we
will ask her family of leave the room so she can calm down.
On 1/22/24 at 10:32 AM, V4 RN stated on 1/10/24, V10 (Family of R1) was shouting at R1 and R1 was
yelling back at (V10) because (R1) initially did not want to go to her appointment. (R1) was all worked up.
We continued to work on getting (R1) up. We got her up off the bed, in the sling. She was still arguing with
her family. She kept moving while in the sling. We told her to cross her legs and arms (during the transfer)
but she wouldn't listen to us. As (R1) raised her arm at (V10) and was screaming, it caused her weight to
shift in the sling. The sling dipped down and came unhooked from the lift. (R1) fell on the ground. It
happened so fast . V4 stated, We shouldn't have transferred her when she was all worked up. We should
have removed her family and given her time to calm down.
On 1/22/24 at 10:50 AM, V10 Family of R1 stated on 1/10/24, R1 was agitated prior to the transfer because,
She was not ready for the doctor's appointment when I got there. She was confused and is very hard of
hearing. She was not sure what doctor she was going to see . V10 stated, The sling part came away from
the lift. (R1) tumbled out of the lift, head first, onto the floor .
On 1/22/24 at 11:15 AM, V3 Nurse Practitioner (NP) stated R1 was hard of hearing and had periods of
confusion. V3 stated, (R1) has anxiety. She can get agitated and refuse cares. Within the past year, she fell
and broke her right femur (upper leg). She was hospitalized where she underwent surgery to repair her
femur. While hospitalized , staff dislocated her previously repaired femur fracture, during a transfer. She had
to go back to surgery again. By the time she got admitted to the facility, she was so scared of being hurt
when transferred or during cares, she was in a full-on panic disorder. She was refusing all cares. I had to
put her on medications initially to help treat her panic disorder. If (R1) gets worked up, agitated, refuses
cares, or is not cooperative, staff should come up with a plan to mitigate her safety concerns. Hold off on
transferring her. Let her express her concerns, then try to reapproach her. If she won't follow staff
instructions such as holding still during a transfer, don't transfer her. Give her time and reapproach. If she is
having behaviors and has an appointment she must go to, slide her from her bed to a gurney, to make sure
she is transferred safely.
On 1/22/24 at 8:54 AM, this surveyor and V9 Maintenance Director examined the mechanical lift and cloth
sling used to transfer R1 on 1/10/24. No defective areas and/or missing parts were noted on the lift. No
weakened areas or holes were noted on the cloth sling. V9 stated there was no way the sling just comes
away from the machine if the loops are secured in place and two staff are doing the transfer. V9 stated
when residents are being transferred via mechanical lift, the resident should be calm to prevent any
resident injury.
On 1/22/24 at 9:50 AM, V8 (Representative of the company that manufactures the mechanical lift used to
transfer R1) stated, We leave it up to the discretion of the facility but we recommend that a resident is in a
calm state when transferring them in a lift. V8 stated if the resident can't be still
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145304
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145304
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Elevate Care Riverwoods
3705 Deerfield Road
Riverwoods, IL 60015
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
and calm, then we don't recommend transferring them to ensure they aren't injured while being transferred.
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145304
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the January 22, 2024 survey of ELEVATE CARE RIVERWOODS?
This was a inspection survey of ELEVATE CARE RIVERWOODS on January 22, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ELEVATE CARE RIVERWOODS on January 22, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.