Inspection·May 6, 2025

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 ensure mechanical lift transfers were safely completed for one (R2) of three residents reviewed for falls in the sample of nine. Residents Affected - Few Findings include: The facility Safe Lifting and Movement of Residents policy and procedure, dated August 2008, documents Mechanical lifting devices shall be used for any resident needing a two person assist. The facility Using a Portable Lifting Machine policy and procedure, dated August 2008, documents The portable lift should be used by two staff members. The facility fall log documents R2 had a change in center of gravity on 4/12/25 at 11:50 AM. The Fall Investigation for R2, dated 4/12/25 at 11:50 AM documents V14 CNA (Certified Nursing Assistant) was transferring R2 with a mechanical lift and during maneuvering R2 in the mechanical lift sling into R2's high back reclining wheelchair a change in center of gravity occurred causing (mechanical) lift to tip over. V14 CNA yelled for help, V15 LPN (Licensed Practical Nurse) overheard V14 CNA yelling for help and observed R2 and V14 CNA pinned up against the dresser with (R2) in (mechanical lift) sling attached to the (mechanical) lift. V15 LPN moved R2's high back reclining wheelchair and assisted V14 CNA in lowering R2 to the floor. The clinical record for R2 documents the following diagnoses: Multiple Sclerosis, Muscle Wasting and Atrophy, Encephalopathy, and Neuromuscular Dysfunction of bladder. R2 is cognitively intact, has functional impairment to one upper extremity and bilateral lower extremities, uses wheelchair for mobility, and is dependent for transfers. R2 is at risk for falls related to Deconditioning and Multiple Sclerosis, uses mechanical lift for transfers with two-person physical assist. On 4/29/25 at 9:09 AM and 1:43 PM R2 was lying in bed with a mechanical lift sling underneath him. On 4/30/25 at 10:57 AM, R2 was sitting up in a reclining high back wheelchair in his room with mechanical lift sling underneath him. On 4/30/25 at 1:15 PM, V7 CNA and V8 CNA entered R2's room, attached the mechanical lift to R2's mechanical lift sling and transferred R2 from the high back reclining wheelchair to R2's bed. On 4/29/25 at 1:43 PM, R2 stated one of the CNAs raised him up in the lift by themself and they had to put him on the floor. R2 stated, I don't know what happened, just started to fall. Now they use (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: 145000 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 145000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Senior Living 1201 Newcastle Washington, IL 61571 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)