Health inspection·December 20, 2024

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to ensure the facility's survey results, including previous five years, were readily and easily accessible to residents for review. This failure has the potential to affect all 73 residents residing in the facility. Residents Affected - Many Findings include: The state Long-Term Care Ombudsman Program Residents Rights for People in Long-Term Care Facilities, dated 11/28/18 documents You (residents) have the right to see reports of all inspections by the (State agency) from the last five years and the most recent review of your facility along with any plan that your facility gave to the surveyors saying how your facility plans to correct the problem. The facility's Statement of Resident Rights policy and procedure within the facility's admission Contract, documents The resident has the right to - Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must - Post in a place readily accessible to residents and family members and legal representatives of residents, the results of the most recent survey of the facility. Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. On 12/18/24 at 10:59 am, during the resident council meeting, R41, R43, R46, R47, and R55 stated they didn't know they could review the facility's survey results, are unaware that the facility is to have easily accessible the State Agency survey results, and do not know the location of the survey results within the facility. On 12/18/24 at 2:45 pm, no facility survey results were found in the facility. On 12/18/24 at 2:50 pm, V1 Administrator approached the receptionist desk and asked V9 Receptionist where the facility's survey binder would be located. V9 Receptionist was unable to confirm where a binder would be located. V1 Administrator looked in multiple drawers in the front lobby area, looked around the resident television area, and confirmed there was no survey binder available in the area for residents to review. The facility's Long-Term Care Facility Application for Medicare and Medicaid CMS (Centers for Medicare and Medicaid Services) 671 Form, dated 12/17/24, documents 73 residents currently reside in the facility. Page 1 of 11 145000 145000 12/20/2024 Washington Senior Living 1201 Newcastle Washington, IL 61571

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to document in the resident's Electronic Medical Record or provide written notification to the resident/resident representative, of the reason for emergent hospital transfer/discharge. This failure has the potential to affect all 73 residents residing at the facility. Findings Include: Facility's Transfer and Discharge Policy (Undated) documents: Policy: To assure resident transfers and discharges will be conducted in accordance with residents' rights, physician's orders, and in such a manner as to maintain continuity of care for the resident. Facility's Notice of a Transfer or Discharge Policy (Undated) documents: Our facility shall provide a resident and/or the resident's representative (sponsor) with appropriate notice of an impending transfer or discharge. Include in written notice to the resident/authorized legal representative the following: i. Reason for transfer/discharge; ii. Effective date of transfer/discharge; iii. Location to which the resident will be transferred/discharged ; 4.d. In the event temporary transfer is made to a physician's office or outpatient clinic, the resident will be informed of their bed hold rights and a transfer form will be completed by a licensed nurse and given to the authorized agency. On 12/18/24 at 2:50pm, V1 Administrator stated that there was no transfer documentation information given to the residents or to the residents' representatives when residents were transferred/discharged out to the hospital. V1 stated, We have had a lot of changes at the facility; and I cannot find paperwork, or written notifications given to responsible parties or to the residents. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) Form, dated 12/17/24, documents 73 residents reside in the facility. 145000 Page 2 of 11 145000 12/20/2024 Washington Senior Living 1201 Newcastle Washington, IL 61571

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interview and record review, the facility failed to provide a copy of the Bed Hold Policy notification to residents/residents' representatives for emergent hospital transfer/discharge. This failure has the potential to affect all 73 residents residing in the facility. Findings Include: Facility's Bed Hold Policy Notification (Undated) documents: This Bed Hold Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room. Facility's Transfer and Discharge Policy (Undated) documents: Policy: To assure resident transfers and discharges will be conducted in accordance with residents' rights, physician's orders, and in such a manner as to maintain continuity of care for the resident. Facility's Notice of a Transfer or Discharge Policy (Undated) documents: 4. d. In the event temporary transfer is made to a physician's office or outpatient clinic, the resident will be informed of their bed hold rights and a transfer form will be completed by a licensed nurse and given to the authorized agency. On 12/18/24 at 2:50pm, V1 Administrator stated that no Bed Hold Policy information was given to residents or to the residents' representative when residents were transferred/discharged to the hospital. V1 stated, We have had a lot of changes at the facility; and I cannot find paperwork, or written notifications given to responsible parties or to the residents. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) Form, dated 12/17/24, documents 73 residents reside in the facility. 145000 Page 3 of 11 145000 12/20/2024 Washington Senior Living 1201 Newcastle Washington, IL 61571

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to complete thorough fall investigations for three (R15, R48, and R49) residents of eight residents reviewed for falls in the sample of 25. Residents Affected - Few Findings include: On 12/18/24 at 8:55 am, V1 Administrator stated V2 DON (Director of Nursing) oversees all the resident falls. The falls are discussed in morning meeting, and they come up with interventions and update the care plans. On 12/19/24 at 9:20 am, V2 DON (Director of Nursing) stated about 85 percent of the Nurses the facility uses are from the local Agency Service, so all I have is what is there. V2 DON stated, Details of the fall is what's missing in the (computer system) and that is all the information V2 has regarding resident falls. V2 DON stated falls are discussed in the morning meetings with the IDT (interdisciplinary team), interventions are decided and placed on the resident's care plan at that time. V2 DON confirmed she does not always know the root cause of the resident fall due to lack of documentation from the Nurses. On 12/19/24 at 11:15 am, V1 Administrator stated the Agency Service Nurses are not good about charting and once they have worked and leave the facility, they no longer have their contact information, and the Nurse doesn't come back here. V1 stated the facility has difficulty contacting the Agency Service and does not always receive a call back when messages are left. 1. The Face Sheet for R15 includes the following diagnoses: Cerebral Infarction, Severe Protein-Calorie Malnutrition, Lumbar Intervertebral Disc Degeneration, Generalized anxiety Disorder, Congenital Spondylolisthesis, Lumbar Radiculopathy, Osteoporosis and Delusional Disorders. The fall investigation for R15, dated 8/17/24 at 12:45 pm, documents R15 had an unwitnessed fall in her room from her chair. This investigation does not include the root cause analysis of R15's fall, progress notes, resident or staff interviews, or interventions to prevent further falls. The fall investigation for R15, dated 8/25/24 at 2:39 am, documents R15 fell out of bed. This investigation does not include the root cause of R15's fall, progress notes, or interventions to prevent further falls. The fall investigation for R15, dated 10/7/24 at 2:29 pm, documents R15 had an unwitnessed fall in her room. This investigation does not include the root cause of R15's fall, progress notes, or interventions to prevent further falls. The fall investigation for R15, dated 10/12/24 at 11:52 pm, does not contain any fall details, progress notes, predisposing factors, interviews, or interventions to prevent further falls. The fall investigation for R15, dated 10/16/24 at 4:34 pm, documents R15 had a fall from her bed. This investigation does not include the root cause of R15's fall, progress notes, potential witness interviews, or interventions to prevent further falls. 145000 Page 4 of 11 145000 12/20/2024 Washington Senior Living 1201 Newcastle Washington, IL 61571

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/17/24 at 3:52 pm, R15 stated she has had previous falls, does not try to get up by herself and needs help to get up. 2. The Face Sheet for R48 includes the following diagnoses: Vascular Dementia with other Behavioral Disturbance, Anxiety Disorder, Weakness, History of Transient Ischemic Attack (TIA) and Cerebral Infarction (Stroke), altered Mental status, Migraine, Cognitive Communication Deficit, and Psychotic Disorder with Hallucinations. The fall investigation for R48, dated 6/24/24 at 1:15 pm, documents R48 was witnessed sliding out of his wheelchair onto floor onto to his right side in the assist dining room. This investigation does not include the root cause of R48's fall, witness statement, progress notes, or interventions to prevent further falls. The fall investigation for R48, dated 7/3/24 at 10:15 am, documents R48 had a witnessed fall, stood up per self and sat on floor. This investigation does not include predisposing fall factors, potential witness or R48's interview, progress note, root cause of R48's fall or fall interventions to prevent further falls. The fall investigation for R48, dated 7/17/24 at 1:00 pm, documents R48 had a witnessed fall, stood up and fell to floor. This investigation does not include predisposing fall factors, witness statements, progress note, root cause of R48's fall or fall interventions to prevent further falls. The fall investigation for R48, dated 8/21/24 at 11:15 am, documents V11 CNA (Certified Nursing Assistant) witnessed R48 attempting to self-transfer and V11 CNA had to lower R48 to the floor. This investigation does not include the root cause of R48 attempting to self-transfer or fall interventions to prevent further falls. The fall investigation for R48, dated 8/22/24 at 1:10 pm, documents R48 had an unwitnessed fall. R48 fell backward out of wheelchair and received a hematoma to back of head. This investigation documents an unnamed CNA (even though documented unwitnessed) stated, Client kicked leg foreword and pushed chair backward falling back and hitting back of head. This investigation does not include the name of the CNA, progress note, or fall interventions to prevent further falls. The fall investigation for R48, dated 9/1/24 at 1:10 pm, documents R48 had an unwitnessed fall. R48 attempted to get up from wheelchair and ambulate. V12 CNA (Certified Nursing Assistant) stated she saw client attempt to get up at nursing station and sat on floor. This investigation does not include the root cause of R48 attempting to self-transfer, does not include required notifications having been made, or progress note. The fall investigation for 48, dated 10/12/24 at 9:42 pm, documents R48 had an unwitnessed fall that was reported by unknown peer. Unknown peer stated R48 tried to stand up from chair and fell. This investigation does not include the root cause of R48 trying to stand up or fall intervention to prevent further falls. The fall investigation for R48, dated 10/24/24 at 1:51 pm, documents R48 had an unwitnessed fall and found on floor in the hallway. This investigation does not include potential witness statements or root cause of R48's fall. The fall investigation for R48, dated 11/28/24 at 10:24 pm, documents R48 had an unwitnessed fall 145000 Page 5 of 11 145000 12/20/2024 Washington Senior Living 1201 Newcastle Washington, IL 61571

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at 8:15 pm in his room. An unknown peer reported R48 on the floor, face down wrapped halfway in sheet. R48 received an abrasion on right knee and left elbow. This investigation does not include potential root cause of R48's fall, progress note or fall interventions to prevent further falls. On 12/17/24 at 3:35 pm, R48 was lying in bed on his back, call light in place. Rolled edge mattress to bed, non-skid strips to the floor. Interview was attempted with R48 and due to cognitive deficits R48 was not interview able. 3. The Face Sheet for R49 includes the following diagnoses: Rhabdomyolysis, Encephalopathy, Moderate Protein-Calorie Malnutrition, Difficulty walking, Lack of Coordination, Weakness, Tracheostomy, Trigeminal Neuralgia, Cellulitis, and Glaucoma. The fall investigation for R49, dated 8/10/24 at 9:00 am, documents R49 had an unwitnessed fall in her room. V12 CNA reported she was assisting R49 with transfer from a commode to wheelchair. V12 CNA's witness statement documents R49 was standing up, pulling her pants up and V12 CNA moved the commode away to empty it and R49 fell backwards on to her bottom. R49's statement documents R49 stated she stood up off the commode and V12 CNA pulled the commode out from behind her to pull her pants up and R49 thought the wheelchair was already behind her, so she sat down but fell to her bottom on the floor. This investigation does not include fall interventions to prevent further falls for R49 and does not include staff education regarding safe transfers. The fall investigation for R49, dated 10/13/24 at 6:13 am, documents R49 had an unwitnessed fall, was calling from down the hall stating she fell. R49 stated she was trying to roll over in bed and slid out resulting in scratch to her neck from the table. This investigation does not include progress note or intervention to prevent further falls. On 12/19/24 at 4:00 pm, R49 stated she has had a few falls since admitting to the facility. R49 stated she did roll out of her bed one morning and told the staff she needed a new mattress because there was a lump in her, and she would slide but the facility never gave her one. R49 stated the facility put nonskid strips on her floor. (Laughing) R49 stated those are not going to stop me from falling out of my bed. The facility's undated Fall policy and procedure documents, In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in cognition or level of consciousness; e. Neurological status; f. Pain; g. Frequency and number of falls since last physician visit; h. Precipitating factors, details on how fall occurred; i. All current medications, especially those associated with dizziness or lethargy; j. all active diagnose. Staff will document risk factors for falling and subsequent falls. The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls. The staff will evaluate, and document falls that occur while the individual is in the facility; for example, where, when and where they happen, any observations of the events, etc. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. If the cause of a fall is unclear, if the fall is unclear . or if the individual continues to fall despite attempted interventions, a physician will review the situation and help identify contributing causes. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls 145000 Page 6 of 11 145000 12/20/2024 Washington Senior Living 1201 Newcastle Washington, IL 61571

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and to address risks of serious consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. 145000 Page 7 of 11 145000 12/20/2024 Washington Senior Living 1201 Newcastle Washington, IL 61571

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to ensure the nurse staffing posting was completed daily, included the total nursing hours worked and failed to retain 18 months of the posting. This failure has the potential to affect all 73 residents residing in the facility. Residents Affected - Many Findings include: On 12/17/24 at 8:45 am, the facility Nurse Staffing Posting was noted to be at the receptionist desk. This form does not include the total hours for Nursing Staff. On 12/19/24 at 2:30 pm, the Nurse Staffing Posting was noted resting on top of the receptionist desk without the total of Nursing hours calculated. V1 Administrator stated this is the form the facility uses for the Nurse Staffing and HR completes the form daily. V1 confirmed there are no total hours documented on this form for CNA's (Certified Nursing Assistants), LPN's (Licensed Practical Nurses), or RN's (Registered Nurses). On 12/19/24 at 2:45 pm, V1 Administrator provided four months (September through December) of Nursing Staff postings. These postings did not include 11/12/24, 12/7/24, 12/8/24, 12/13/24, 12/14/24, and 12/15/24. All four months do not include the total number of nursing hours worked. On 12/19/24 at 3:37 PM, V1 Administrator stated he was only able to locate four months of the Nurse Staff Posting for the facility and does not have anything further to provide. On 12/20/24 at 1:00 pm, V10 HR (Human Resource) Director stated the Nurse Staffing posting was given to her to do after the former administrator left and she wasn't sure exactly what information needed to be on the form or that the hours had to be totaled. V10 stated the sheets are posted daily and are not updated to reflect the actual number of nursing staff or nursing hours that were worked. The facility's Long-Term Care Facility Application for Medicare and Medicaid CMS (Centers for Medicare and Medicaid Services) 671 Form, dated 12/17/24, documents 73 residents currently reside in the facility. 145000 Page 8 of 11 145000 12/20/2024 Washington Senior Living 1201 Newcastle Washington, IL 61571

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to have a routine cleaning schedule for the kitchen, document or have an expiration date for bread, keep the floor and steamer oven clean, store food off the floor, keep sanitization logs for the dishwasher, and keep freezer/cooler/refrigerator temperature logs. These failures have the potential to affect all 73 residents living in the facility. Findings include: On 12/18/24 at 1:09PM, during the tour of the kitchen there was no cleaning schedule posted for staff, and no cleaning check off sheets for the staff; multiple boxes of food stacked on top of one another in the middle of the freezer on the floor; no sanitization logs posted or able to be provided for the dishwasher; no freezer or cooler/refrigerator temperature logs posted on the freezer or cooler/refrigerator and unable to be provided; eight/8 loaves of bread were on the food storage racks with no delivery date, box, or expiration date on the bread; the kitchen steamer/oven had a build-up of a black sticky substance on the bottom; and the kitchen floors had brown streaks and dirt/debris accumulated. On 12/18/24 at 1:09 PM, V6 DM/Dietary Manager stated (when on the tour of the kitchen) the following: that she has been in the DM position since July 2024; does not have a cleaning schedule for the kitchen staff, and no check off sheets for the staff to use when they clean to document what was cleaned and by whom; freezer food was delivered late last night (12/17/24) and she has not put it away yet (at 1:09PM); I am not sure where those are at (dishwasher sanitization logs), probably in a drawer somewhere; I am not sure where the temperature logs for the cooler or freezer are; I did not know they did not have the expiration date on the bread anymore; We clean the stoves and steamers monthly; and I don't have a routine clean check list for my staff, I probably need to do that because there is no set cleaning schedule on what they are to clean when working. Facility Diet Type Report, dated 12/20/24, documents all 73 residents get food out of the dining room except for one (R222) who is NPO/nothing by mouth. The Facility Long term care application for Medicare and Medicaid, dated 12/17/24, documents 73 residents currently reside in the facility. Facility Food Storage (Dry, Refrigerated, and Frozen), dated 2020, documents Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Set refrigerators to the proper temperature and the setting must ensure the temperature of the food is 41 degrees or lower. Conduct random temperature checks of food items. Keep freezer at a temperature that ensures products will remain frozen (0 degrees). Check freezer temperature regularly. Store food six inches off the floor to allow for proper sanitation. The Dining Services Manager will record the necessary cleaning and sanitation tasks for the department. All staff will be trained on the frequency of cleaning. A cleaning schedule will be posted for all cleaning tasks. 145000 Page 9 of 11 145000 12/20/2024 Washington Senior Living 1201 Newcastle Washington, IL 61571

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to have a procedure to reduce the risk of Legionella in the facility's water system. This failure has the potential to affect all 73 residents living in the facility. Residents Affected - Many Findings include: On 12/17/24 at 11:28AM and during the survey through 12/20/24, V3 Maintenance Director was unable to provide any information/documentation on the facility's Legionella procedures, water system, or risk assessment. On 12/17/24 at 11:28 AM, V3 Maintenance Director stated, I do not flush the pipes for Legionella or have a water management plan. What is that? All I do is check temperatures on the hallways weekly for the water temperatures, and I have been here since February 2024. On 12/18/24 at 10:00 AM, V4 IP/Infection Preventionist stated, I don't do anything with Legionella Disease water plan at all, and we have had no residents with Legionella. The Facility Long term care application for Medicare and Medicaid, dated 12/17/24, documents 73 residents currently reside in the facility. Facility Water Management Program, undated, documents It is the policy of this facility to establish procedures to reduce risk of Legionella and other opportunistic pathogens. The Maintenance Director will maintain documentation that describes the facility's water system. A risk assessment of water system components will be conducted. Based on the risk assessment, control measures will be established to address potential hazards. Routine infection control surveillance data will be used to validate the effectiveness of the water program. The facility will conduct an annual review of the water management program. The infection preventionist will maintain documentation of all the activities related to the water management program. 145000 Page 10 of 11 145000 12/20/2024 Washington Senior Living 1201 Newcastle Washington, IL 61571

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review, the facility failed to maintain documentation of COVID-19 staff vaccinations, screening, offering, or education. This failure has the potential to affect all 73 residents living in the facility. Findings include: Facility COVID-19 Vaccine, effective 1/4/21, documents, The Infection Control Coordinator will maintain surveillance data on COVID-19 vaccine coverage. Surveillance data will be made available to staff as part of educational efforts to improve vaccination rates among employees. On 12/18/24 at 10:00AM and during the survey through 12/20/24, V4 IP/Infection Preventionist was unable to provide any documentation regarding staff COVID-19 vaccinations, screening, offering, or education. On 12/18/24 at 10:00 AM, V4 IP stated, I don't know what staff is fully vaccinated or not for COVID-19. I have not screened, educated, or offered staff the COVID-19 vaccination. The Facility Long term care application for Medicare and Medicaid, dated 12/17/24, documents 73 residents currently reside in the facility. 145000 Page 11 of 11