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 ensure a resident was transferred with two
people while using a mechanical lift as shown in the facility's policy.
This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 5.
The findings include:
On November 25, 2024 at 9:01 AM, R1 was sitting in the dining room in a high back wheelchair. R1 was
unable to answer questions due to her cognitive status.
On November 25, 2024 at 10:28 AM, R1 was transferred to her bed from the high back wheelchair using a
mechanical lift. V8 (CNA-Certified Nursing Assistant) provided incontinence care to R1. As V8 removed
R1's pants, a four-by-four-inch dressing was visible on R1's left shin. The date 11/24 was written on the
dressing. The dressing was dry and intact. No bruising was noted.
The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple
diagnoses including, senile brain degeneration, dementia with agitation, depressive episodes, dysphagia,
hypertension, and restlessness and agitation.
R1's MDS (Minimum Data Set) dated October 16, 2024 shows R1 has severe cognitive impairment,
requires substantial/maximal assistance with eating, personal hygiene, and bed mobility, and is dependent
on facility staff for transfers between surfaces, lower body dressing, showering, toilet hygiene, and oral
hygiene. R1 is always incontinent of bowel and bladder.
R1's mechanical lift care plan, initiated on March 16, 2024, and revised on May 17, 2024 shows multiple
interventions. The goal of the mechanical lift transfer care plan, also initiated on March 16, 2024 shows: I
will be able to transfer with the use of the [total body mechanical lift] safely from bed to chair and vice versa
with 2-person assist. The following intervention was initiated on March 16, 2024: There will always be 2 staff
to assist resident. One staff will control the lift as the other will guide resident and support back and neck to
transfer surface. The following intervention was initiated on May 17, 2024: Updated room signage related to
[total body mechanical lift] transfers x 2 assist.
On November 3, 2024 at 2:59 AM, V7 (RN-Registered Nurse) documented R1 was being transferred using
a total body mechanical lift by the CNA on November 2, 2024 at 9:00 PM. R1 slid out of the mechanical lift
to the floor between the bed and the mechanical lift. V7 noticed a skin tear on R1's left
(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 2
Event ID:
145458
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
145458
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alta Rehab at Oak Brook
2013 Midwest Road
Oak Brook, IL 60521
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
lower extremity. R1 denied discomfort or pain, the skin tear was cleaned with normal saline, and a dressing
was applied. R1 was assessed by facility staff and hospice nursing staff, and no further injuries were
identified.
On November 25, 2024 at 11:17 AM, V2 (DON-Director of Nursing) said, On November 2, 2024, [R1] was
transferred from the chair to the bed using a [total body mechanical lift]. [V3] (Agency CNA) failed to ask
another staff member to assist her. There are supposed to be two CNAs present when using a mechanical
lift, but [V3] was alone. All agency staff are educated on our transfer protocols. She was trying to get [R1]
back into bed as quickly as possible. There was an issue where the sling came unhooked on one side and
[R1] fell from the sling onto the floor and sustained a skin tear to her shin. V2 continued to say R1 did not
sustain any other injury following the fall from the mechanical lift.
The facility's policy entitled, Transfers - Manual Gait Belt and Mechanical Lifts revised 1-19-18 shows:
Purpose: In order to protect the safety and well-being of the staff and residents, and to promote quality
care, this facility will use mechanical lift devices for the lifting and movement of residents. Guidelines: 1.
Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be
transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or
unavoidable circumstances, manual lifting is not permitted.5. The transferring needs of residents will be
assessed on an ongoing basis and designated into one of the following categories: 0 = Independent. 1 = 1
person transfer. 2 = 2 person transfer with gait belt (only when use of mechanical lift is not possible). SS =
sit-to-stand lift with 2 caregivers. H = Mechanical lift [total body mechanical lift] with 2 caregivers.8. Failure
to comply with the lifting guidelines may result in disciplinary action as deemed appropriate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145458
If continuation sheet
Page 2 of 2
