Inspection·December 12, 2024

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. Based on interview and record review, the facility failed to safely transfer a resident through a mechanical lift from her wheelchair to her bed. This resulted in R1 having a fall. This applies to 1 of 3 residents (R1) reviewed for transfers in a sample of 6. The findings include: On 12/10/24 at 11:15 AM, V2 (DON-Director of Nursing) stated, (R1) is no longer here. She was discharged AMA (Against Medical Advice). She was a 2 person assist with a (mechanical lift). She came to us on 11/4/24. On 11/11/24, (R1) was getting transferred from her wheelchair to the bed after dialysis in her room with the mechanical lift. (V4--Former CNA/Certified Nursing Assistant) and (V3) were the CNA's that were transferring her. (V3) no longer works here. (R1) was moving around in the sling while they were transferring her. She wouldn't stop. She slid off the sling and fell to the floor. She had no injuries. (R1) was sent to the hospital. X-rays were done and everything was normal. Falls are not supposed to happen when you transfer a resident using the (mechanical lift). On 12/10/24 at 11:55 AM, V3 (CNA) stated, On 11/11/24, (V4) was the assigned CNA for (R1). (V4) came to get me to help her transfer (R1) from her wheelchair to her bed with a (mechanical lift). (R1) can roll and move side to side very well. She doesn't walk. Her butt and her side were sore because she had a pressure sore. She was complaining of pain. (V4) was pulling and maneuvering the (mechanical lift), while I was guiding (R1)'s legs. She was moving around too much. I told her to stop moving around. She kept saying her leg was sore and she was having a lot of pain from her buttocks to her leg. We adjusted the sling. All 4 hooks were on there. Unfortunately, she just tipped out. The lift was not malfunctioning. We got V11 (LPN-Licensed Practical Nurse) who was (R1)'s nurse that day to come assess her. She had no injuries. 911 was called and she was sent to the hospital. On 12/11/24 at 11:58 AM, telephone interview was done with V11 (LPN). V11 stated, Another CNA who was in passing called me and told that (R1) fell from the (mechanical lift). I went there and (R1) was on the floor. (V3) and (V4) were next to her. She had a huge wound in her body. She was wiggling and it probably hurt her while she was in the sling. She was already in a high position in the air, so I don't think it was a good idea for the CNA's to stop. She just fell out of the sling. We didn't expect this to happen. There were no injuries. But, because she hit her head, we sent her out to the hospital. Everything, all the tests was normal at the hospital. R1's fall incident report dated 11/11/24 shows: During the transfer after dialysis, while in the air, hanging on the sling (Mechanical lift transfer), (R1) moved and slid from the sling down on the floor, hitting her head during the process. She stated that her wound was hurting, so she moved to release the pressure. Complete body assessment done. (R1) was having pain of the head. No lump/bump (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 4 Event ID: 145795 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 145795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tower Hill Healthcare Center 759 Kane Street South Elgin, IL 60177 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)