Health 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 Page 1 of 2 145000 145000 05/06/2025 Washington Senior Living 1201 Newcastle Washington, IL 61571

F 0689 two people all the time. Level of Harm - Minimal harm or potential for actual harm On 4/30/25 at 10:57 AM, V7 and V8 CNAs stated all mechanical lift transfers are to be done with two staff. Residents Affected - Few On 4/29/25 at 11:08 AM, V2 DON (Director of Nursing) stated she did the investigation for R2's fall. R2 was being transferred with the mechanical lift by V14 CNA (Certified Nursing Assistant) and had to be lowered to the floor. V2 DON stated V14 CNA transferred R2 by herself and there should have been two staff. V2 DON stated she just did an in-service and re-educated everyone that mechanical lift transfers are to be done by two staff members always. V2 DON also stated the staffing schedule is now being done differently so that there is always someone available to assist when needed. On 5/26/25 at 12:49 PM, V14 CNA stated after giving R2 a shower she was transferring R2 with the mechanical lift from R2s bed to his high back reclining wheelchair. V14 grasped the mechanical sling to pull R2 back to position him in the wheelchair and the next thing I know the wheelchair and (mechanical lift) tipped. I did it like I always do. V14 CNA stated she yelled for help and V15 LPN came and helped V14 to remove the mechanical lift straps and lower R2 to the floor. When V14 CNA was asked what she could have done to prevent R2s fall V14 stated I could have had another person helping me. The Disciplinary Report for V14 CNA, dated and signed 4/18/25, documents on 4/12/25 V14 CNA performed an improper transfer of a resident (R2). V14 CNA was given a Final Warning on 4/18/25 with the corrective action for V14 CNA to use two people when transferring residents with a mechanical lift. 145000 Page 2 of 2