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 observation, interview and record review the facility failed to use safe transfer technique during a
mechanical lift transfer. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in a
sample of 3. This failure resulted in R1 incurring a laceration of her lip requiring sutures.
Findings include:
R1's admission Record dated 8/21/2023 documents R1 with diagnoses to include Anxiety, Ataxia, Stroke,
Paralytic Syndrome, and Blind left eye.
On 8/21/2023 at 11:20 AM R1 was transferred by facility staff from an adaptive reclining chair to her bed
using a mechanical lift.
R1 was noted with a healed wound to her upper left lip, both legs were contracted with her knees drawn up
and with spastic movements to her upper body.
A facility Final Investigative Report dated 8/10/2023 documents on 8/6/2023, R1, who utilizes a mechanical
lift due to poor trunk control and limited range of motion, slipped from the mechanical lift sling as she was
being transferred from her bed to an adaptive reclining chair. This report documents R1 was transferred to
the hospital for evaluation and treatment, returning with steri strips to her left eyebrow and sutures to her
left upper lip.
8/21/2023 3:22 PM V6 (Nursing Assistant) stated she provided morning care to R1, placed the mechanical
lift sling pad under her and attached the sling loops to the lift machine before V5 (Nurse) came to the room
to assist with the transfer. V6 stated she attached the red loops for the upper body and the black strap loops
to the bottom body portion of the sling. V6 stated as she lifted R1 up with the machine and moved her over
the bed they began to turn her towards the adaptive reclining chair. As R1 was being turned V5 yelled, She
is falling, she is coming out of the sling and R1 fell onto the floor. V6 stated she positioned the sling loops
on the black strap loop so that her legs extended out. V6 confirmed all 4 sides of the sling loops were
attached and the sling remained attached to the lift machine during the transfer.
8/22/2023 8:32 AM V7 (Restorative Nurse) stated she conducts all the training for use of the mechanical lift
machines. V7 stated slings have 3 colored loops to attach during a transfer and the black strap loop is a
safety strap to ensure if one of the colored loops breaks the black strap will catch on the machine. V7 stated
the black strap loop is not supposed to be hooked up and used during a transfer. V7 stated, R1's lower
body is very contracted, further stating, she is not sure how V6 could
(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:
145892
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
145892
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunny Hill Nursing Home of Will County
421 Doris Avenue
Joliet, IL 60433
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
be extending her legs out. V7 confirmed placing the bottom part of the sling on the black strap loop would
place her lower body in a much lower position than her upper body and would likely be the cause of the fall.
Level of Harm - Actual harm
Residents Affected - Few
On 8/21/2023 at 8:55 AM V2 (Director of Nursing) confirmed if R1 was placed correctly in the sling she
should not have slipped out.
On 8/22/2032 at 11:32 AM V18 (Nurse Practitioner) stated she evaluated R1 after the fall from the lift and
she had sutures to her lip and some bruising. V18 stated she expects the facility to use correct safety
interventions to prevent residents from slipping from or falling out of the mechanical lift sling during use.
A Health Status Progress Note dated 8/6/2023 documents R1 returning from the emergency room with 4
sutures to her upper left lip, steri-strips to her left eyelid laceration and swelling to her left side of her face.
R1 was provided pain medication for left shoulder and facial pain rating a 7 out of 10.
R1's Care Plan dated 10/22/2021 documents R1 with deficits due to Cerebellar Ataxia, Stroke, Dementia
and Blindness requiring the use of a mechanical lift for transfers.
The facility policy, Electric Lift Transfer, last reviewed 1/20/2023 documents it is the policy of the facility to
use the electric lift appropriately to facilitate safe resident transfers.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145892
If continuation sheet
Page 2 of 2
