Health inspection·January 5, 2026

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 with the mechanical stand lift who has a history of falls. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's face sheet shows she has diagnosis including hypertensive heart disease and chronic kidney disease stage 4, atrial fibrillation, type 2 diabetes, repeated falls, reduced mobility, depression, generalized osteoarthritis, and anxiety. On 01/5/26 at 11:42 AM, V8 (Agency Certified Nursing Aide/CNA) said on 12/25/25, she received report R1 had a fall the day before and was a two person assist or mechanical stand lift. She went to find another staff member to assist her with the transfer. The other aide was busy, and she could not find staff to help her. She said she used the stand lift to transfer R1 by herself. V8 said she placed the sling under R1's armpits and secured the belt around her chest. During the transfer, R1's legs gave out, and she started to slip from the sling strap. She fell and hit her lower back on the floor. V8 said this was her first time working at the facility and she did not know when using the mechanical stand lift two staff should be assisting. She called for help, and another CNA came in, and they lifted her off the floor and placed her in the wheelchair. I should have asked the staff to assist me even though she was a stand lift and should have not lifted her off the floor until the nurse came. On 01/5/26 at 10:45 AM, V5 (Restorative CNA) said on 12/25/25, V8 was asking for the nurse and reported R1 was having pain. She did not know R1 fell from the stand lift. V8 mentioned R1 fell the day prior. R1 was a two person assist, she was alert to self and could not communicate all of her needs. Stand lifts are always two people assist. Staff should place the sling and secure the strap. If you don't have the strap in the right position, it could be a safety issue. The sling should be placed around the waist and not under the arm pits. Our lift policy is two staff are required with transfers, and all staff should know that. On 01/5/26 at 12:45 PM, V2 (Director of Nursing) said R1 had a fall from the stand lift. V8 (Agency CNA) did not follow our policy on mechanical transfers using two staff for transfers. When a resident falls staff should not move the resident until the nurse does her assessment and a resident should not be lifted off the floor. Staff should use the mechanical lift to transfer the resident off the floor for safety measures. When staff entered the room the mechanical stand lift arms were in an upright position and that will cause the sling to ride up the back. The sling should be placed around the back, and the buckle needs to be secured. That's what is going to catch them. We have an agency binder at the nurse's desk. It's ideal they look at it and its basic CNA knowledge when using the mechanical lift. R1's Incident Report dated 12/25/25 shows (V8) stated (R1) had slipped out of sit to stand machine and the sit to stand arms were in the upright position in R1's room. V8 reported moving R1 off the floor after the fall. R1's current care plan shows; is at high risk for fall due to history of falls and impaired mobility with interventions to use stand lift for transfers. R1's care plan shows she had a fall on 12/24/25 due to weakness. The facility's Transfer Policy/Use of Mechanical Lifts and Pivot Transfers revised 2019 states, two (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: 146177 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 146177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Resthave Home-Whiteside County 408 Maple Avenue Morrison, IL 61270 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)