Health inspection·February 2, 2026

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 interview and record review the facility failed to safely transfer 1 of 3 (R1) residents reviewed for accidents in a sample of 7. This failure resulted in R1 falling out of a whole-body lift machine onto the floor and sustaining a right hip fracture, a fracture of the distal right femur and a fracture of the right tibia.This past noncompliance occurred on 1/24/2026.Findings included:R1's admission Record documents R1 was admitted to this facility on 5/20/2025 with diagnoses of dependence on dialysis, end stage renal disease, morbid obesity and chronic obstructive pulmonary disease among others.R1's MDS (minimum data set) dated 11/15/25, documents R1 needs two staff assistance for all transferring activities and the staff utilize a full body lifting machine for lifting R1. R1's MDS documents R1 has a BIMS (Brief Interview for Mental Status) of a 15 indicating R1 has no cognitive impairment.R1's care plan documents a focus area of: R1 has impaired physical mobility related to decreased strength, limited weight bearing tolerance and dependence on mechanical lift for transfers. Date initiated as 1/24/26.A facility document titled Long Term Care Facility-Serious Injury Incident Report for R1 dated 1/24/2026 documented the following in part: At approximately 0900 hours (9:00 am) two CNAs (Certified Nurse Assistants) went into the resident's room to get her out of bed using the mechanical lift. They attached the sling to the lift and raised the resident up over her bed and weighed her. After obtaining the weight on the resident they went to place her in her wheelchair. According to both CNAs, the bottom right strap slipped off the hook on the mechanical lift and the resident slid out of the sling onto the ground. R1 was transported to the hospital. Hospital called and notified the facility that R1 has suffered a hip fracture, femur and upper tibia fractures.On 1/28/2026 at 1:25pm, V5 (CNA) said on 1/24/26 around 8:45am, she and V6 were transferring R1 into her wheelchair from bed using the (mechanical) lift and a bariatric sized sling. V5 said she operated the machine while R6 maneuvered the wheelchair. V5 said while the lift machine was moving with R1 up in the air, R1's sling hook on the bottom, slipped off and R1 fell to the ground. V5 said she ran and got help while R6 stayed with R1. V5 stated R1 was transported to the local hospital emergency room (ER) via EMS (Emergency Medical Services). V5 said after R1 was sent to the ER, they looked over R1's sling and found nothing wrong with it. V5 said it was in perfect working order. On 1/29/26 at 11:00am, V6 (CNA) said on 1/24/2026 around 8:45am, R1 was ready to get out of bed after breakfast because her family was coming to spend the day with her from out of town. V6 said she and V5 (CNA) prepared R1 for transfer by placing R1's bariatric lift sling underneath R1 and hooking the sling straps to the lifting machine. V6 said she hooked the bottom straps while V5 hooked the top straps. V6 said V5 began to lift R1 up into the air with the lifting machine, while V6 got R1's wheelchair ready for R1 to be lowered down into the wheelchair. V5 said while they were moving the lift machine with R1 up in the air, the bottom right strap of R1's lift sling slid off the machine causing R1 to fall to the floor. V5 said she must not have gotten the strap on the machine correctly. V5 said the nurse immediately came and R1 was sent to the local emergency room for treatment of Page 1 of 2 146096 146096 02/02/2026 The Haven of Ridgeview 413 Ridge Lane Oblong, IL 62449

F 0689 Level of Harm - Actual harm Residents Affected - Few injuries.On 1/29/26 at 10:15am, V7 (Registered Nurse) said she worked on 1/24/26 and was the nurse providing care for R1 on that day. V7 said around 8:45am that morning, V5 and V6 were getting R1 up in her wheelchair for daily activities using a whole-body lifting machine. V7 said one of the sling straps slid off the machine and R1 fell to the ground. V7 said she could tell R1's leg was injured so no one moved R1 until EMS (emergency medical services) arrived to transport R1 to the local emergency room for evaluation. V7 said R1 ended up with a fractured right hip, right femur and right tibia.On 1/28/2026 at 11:10am, V9 (Family) said on 1/24/2026 at around 9:00am, she received a call from the nursing home reporting R1 had fallen and would be transferred to the local emergency room for evaluation of injuries. V9 said after getting to the hospital to see R1, R1 told her V5 and V6 were using the whole-body lifting machine to transfer R1 from her bed to her wheelchair, when the bottom right lifting strap slipped off the lifting machine and R1 fell to the ground.Local emergency room records for R1 dated 1/24/2026 documented R1 was seen for injuries sustained after falling from a mechanical body lift machine at the nursing home when being transferred by staff into her wheelchair. These records documented R1 was diagnosed with right hip fracture, a fractured distal femur and right tibia fracture. Prior to the survey date, the facility took the following actions to correct the noncompliance:1.The facility held a QAPI (Quality Assurance and Performance Improvement) meeting on 1/24/2026 with V1 (Administrator) and V18 (Care Plan Coordinator). The QAPI meeting note documented the following was implemented on 1/24/2026. 1.) What actions will be accomplished for the identified resident? Assessed the resident's condition immediately. Notified the medical doctor and family about the incident and sent the resident to the hospital for evaluation and treatment. Completed 1/24/26. 2.How will we identify other residents having the potential to benefit for the Quality Assurance Performance Improvement and what actions will be taken? All residents who require mechanical lifts for transfers will be identified. Their care plans will be reviewed and updated as necessary. Staff will be reminded to always seek assistance when needed and to follow proper transfer protocols. The staff involved in the above transfer will be prohibited from transferring with a mechanical lift until educated and their skills observed and checked off on the Mechanical Lift Application and Use check-off list. Completed 1/24/26. 3. What measures will be put into place or what systemic changes will be made? Re-educate all nursing staff on proper mechanical lift techniques and the importance of seeking assistance. Conduct audits to ensure staff compliance with transfer protocols. Ensure that all necessary equipment, such as mechanical lifts are readily available and in good working condition. All staff members using mechanical lifts will be observed and pass the Mechanical Lift Application and Use check-off list. A copy of the Mechanical Lift Application and Use check off list is to be placed in the CNA informational binder for reference at any time. Completed 1/24/26. 4.How the facility plans to monitor the system performance? Weekly audits for 4 weeks, monthly thereafter. The results of these audits will be reviewed by the facility's Quality Assurance Performance Improvement committee for patterns, trends and continued recommendations for process monitoring and improvement. 146096 Page 2 of 2