Health inspection·October 20, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Page 1 of 3 145416 145416 10/20/2025 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain full mechanical lifts in safe/operable condition. This failure has the potential to affect eight of eight residents (R3-R10) reviewed for full mechanical lifts in the sample list of 10. Findings include:On 10/20/25 at 10:10 AM R3 was sitting on a full mechanical lift sling in her wheelchair. R3 stated yesterday the full mechanical lift wasn't working so V7 Certified Nursing Assistant (CNA) used the sit to stand lift to transfer R3 from her wheelchair into bed. R3 stated during the transfer R3 said Dear Jesus please don't let me fall. R3 stated there have been frequent problems with the full mechanical lift not working properly and yesterday the lift would not raise, it would only lower.On 10/20/25 at 1:02 PM R4 was sitting on a full mechanical lift sling in R4's room. R4 stated the staff had trouble getting the full mechanical lift to work this morning and had to go get another lift. At 1:17 PM V15 and V17 CNAs entered R4's room and used a full mechanical lift to transfer R4. V16 CNA went to use another full mechanical lift located in the alcove across the hall from R4's room. This lift contained gray adhesive tape around the housing compartment that covered the gear box and the lift would not raise when the handheld remote was activated. V16 stated the lift is not working properly, it won't raise and only lowers, and the adhesive tape has been there for a long time. V16 demonstrated that the emergency release function was broken, sliding up and down the shaft of the lift. V16 stated it has been like that for a long time and V14 Maintenance was aware of the lift issues. V16 stated the facility needs new lifts, they are always broken. V16 stated the facility has two full mechanical lifts which are used for currently eight residents.On 10/20/25 at 1:27 PM V15 CNA stated the full mechanical lift (referencing the lift in the alcove near R3's room) has been taped like that for at least the three years that V15 has been employed by the facility. V15 stated the emergency release has also been broken for quite a while, and V14 is aware. V15 stated V15 had to take the lift from the South hall since they discovered this morning that this lift was not working.On 10/20/25 at 1:28 PM V15 and V17 used the same full mechanical lift used for R4's transfer to transfer R3 from the wheelchair into bed. At 1:33 PM V15 and V17 stated the emergency release on this lift hasn't worked for quite some time. V15 demonstrated the emergency release did not function.On 10/20/25 at 1:37 PM V14 stated V14 has been the maintenance director since July and has not received any work orders for the full mechanical lifts. V14 stated there are no routine checks performed on the lifts for maintenance and functioning. V14 inspected the two full mechanical lifts that were on R3's/R4's hallway and confirmed the lift with the tape does not raise, and both emergency releases were not functioning. V14 took the remote from the other lift and attached it to the lift with the tape and used it to raise the boom. V14 stated it is a remote/cord issue. V14 stated the tape is used to keep the cover of the gear box in place, which was already there when he started working for the facility. V14 stated staff are to report mechanical lift issues to V14.On 10/20/25 at 2:28 PM V8 Minimum Data Set Coordinator provided a handwritten list of residents, R3-R10, who use the full mechanical lift.The facility's Using a Mechanical Lift policy dated July 2017 documents Test the lift controls. Ensure the emergency release feature works. If the mechanical lift is not deemed in working order, it shall be removed until repaired.The facility's Safe Lifting, Transferring and Movement of Residents policy dated July 2017 documents Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order.The User Manual for (full mechanical lift) dated 2023, provided by V1 Administrator, documents to use the hand pendant to raise and lower the boom and activate the emergency lowering device in the event of power failure or emergency. This manual documents to perform routine inspections of the lift and sling for cracks/damage, wear or fraying of straps or fabric, proper function of wheels and Residents Affected - Some 145416 Page 2 of 3 145416 10/20/2025 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0908 brakes, and condition of electrical cables and connections. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 145416 Page 3 of 3