Health inspection·December 28, 2023

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 safely transfer a resident from her bed to her reclining wheelchair using a mechanical lift, resulting in a fall and skin tear. This applies to 1 of 3 residents (R1) reviewed for mechanical lift use. Findings Include: R1's 12/21/23 nursing note from 7:57 AM showed, Called to resident room by CNA [Certified Nursing Assistant]. Observed resident lying on her right side next to the wall by the foot of her bed, [mechanical lift] sheet partially underneath her. Blood noted by her right lower leg area .resident unable to say what transpired .CNA stated that during transfer [mechanical lift] started to tip over and as she (CNA) reached for the resident to prevent the fall the [mechanical lift] tipped anyway but she was able to break the fall so the resident did not hit the floor with her full body weight . The note showed 911 was called and R1 was transferred to the local Emergency Room. R1's nursing note from 11:30 AM showed she was returning and Xray [NAME] a CT scan were negative. R1 no longer resides in the facility. On 12/21/23 at 1:14 PM, V5, CNA (Certified Nursing Assistant), was interviewed with V6 (CNA). V5 stated they were the staff members that transferred R1 when R1 fell. V5 described the preparation process for R1's mechanical lift transfer. V5 stated once R1 was lifted up from the bed, the rolled the mechanical lift over to the wheelchair, and from there opened the legs of the lift to go in from the side. V5 stated she was behind R1, and V6 was steering the mechanical lift with R1 in it. V5 stated the lever on the machine was locked. V5 stated they heard a noise and the hydraulics on the lift started lowering R1 very quickly. V5 stated she tried to grab the cloth handle from R1's lift sling to pull her back and the machine moved to the left a little. V6 stated she noticed a little blood on R1's left leg and an older skin tear broke open. V6 stated it was about 5 centimeters. V6 stated R1 never complained any pain. On 11/26/23 at 2:15 PM, V7 (Maintenance Director) stated he had checked the lift and completed full maintenance on the lift the day R1 fell, and there was nothing wrong with it mechanically. V7 stated that the Control Valve might not have been completely locked. V7 raised the lift up and down and checked the base and it was fully functional. V7 stated once the control valve is closed (to the left), the machine should lock and be able to go up and down. V7 stated, The control valve once it is closed to the left, it raises the lift with the resident. Once you open it or turn to the right, it lowers the lift with the resident. It was a human error; there was nothing wrong with the machine. (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: 146077 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 146077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Serenity Estates at Morris 1223 Edgewater Morris, IL 60450 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)