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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to safely transfer a resident (R1). This failure
resulted in R1 being hit in the head with the arm of the mechanical lift, resulting in a large skin tear, being
admitted to the hospital, and requirng sutures to her head. This applies to one of three residents (R1)
reviewed for safety in the sample of five.
The findings include:
The facility assessment dated [DATE] shows R1 to be cognitively intact, requires maximum assistance for
her activities of daily living and uses a mechanical lift for her transfers.
On 12/21/23 at 11:15 AM, R1 said she was being lifted from her bed to her wheelchair using the
mechanical lift. R1 said as she was being lowered to her wheelchair, the arm bar on the lift hit her in the
head. R1 said she saw stars and was in a lot of pain. R1 said she had to be taken to the hospital for
sutures, and had to spend the night and have scans to her brain to rule out a brain injury. R1 said she was
very scared and in a lot of pain after the incident.
On 12/21/23 at 12:15 PM, V8 Certified Nursing Assistant (CNA) said she was one of the two CNA's
transferring R1 when she hit her head. V8 said she was directing the lift and the other CNA (V10) was
guiding R1 into her chair. V8 said after R1 was in the chair she moved forward and hit her head on the bar.
On 12/21/23 at 12:40 PM, V10 said he was assisting with the transfer of R1 into her wheelchair. V10 said
R1 hit her head on the lift bar and it began to bleed. V10 said it happened so fast, but he did not remember
where he was during the transfer.
On 12/21/23 at 2:23 PM, V2 Licensed Practical Nurse (LPN) said he does the staff training for the
mechanical lifts and the staff are trained to always have two staff present, one staff is to drive the lift and
the other staff is responsible for guiding the resident safely to their chair or bed. V2 said the lift used for the
incident was pulled from use. It was inspected and a padding was added to the arm of the lift.
Observations of the facility mechanical lifts was completed on 12/21/23. Numerous mechanical lifts were
observed in the facility. Only one lift was observed with padding to the arm of the lift and was located on the
first floor. R1 resides on the second floor. A mechanical lift was observed outside R1's room, but no padding
was observed to the arm of the lift.
(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:
145621
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
145621
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion of Waukegan
2217 Washington Street
Waukegan, IL 60085
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
The facility report regarding the incident dated 11/23/23 shows R1 recieved a skin tear to her right forehead
measuring approximately 10 centimeters. A pressure dressing was applied, 911 was called and R1 was
sent to the local hospital.
The emergency room report dated 11/23/23 shows R1 had a mechanical lift dropped on her head, which
required nine staples and 14 sutures to her right forehead and scalp. The open area was reported to be
approximately 12 centimeters in length. R1 was kept at the hospital overnight to rule out brain injury.
The facility total mechanical lift competency checklist with a revision date of 4/2008 shows a).two
caregivers are present during the transfer, h) gently raises the resident minimally from surface, i). turn
resident legs toward the perpendicular support bar during the move and j). gently lower the resident into
proper position.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145621
If continuation sheet
Page 2 of 2
