Health inspection·August 6, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review the facility failed to notify the Residents Family/Representative promptly of a change of condition for one of three residents (R1) reviewed for injury of unknown origin in the sample of three. Findings include: The Notification of Resident Change in Condition Policy (undated) documents Policy: It is the policy of this facility to promptly notify the resident, their legal representative(s) and attending physician of changes in the resident's health condition. Policy Specifications: To establish guidelines for assuring residents, their legal representatives and attending physicians are informed of changes in the resident's condition. Responsibility: Director of Nursing and Licensed Nurses. Standards: 1. A licensed nurse shall promptly inform the resident, consults with the resident's physician and if known, notify the residents legal representative or an interested family member of: a. An accident involving the resident in which there is a potential for an actual injury which could require nursing or medical intervention. b. A significant change in the resident's physical, mental or psychosocial status, i.e. (example) deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complication. c. A need to alter treatment significantly i.e. need to discontinue an existing form of treatment. d. A decision to transfer or discharge the resident from the facility. 2. The licensed nurse is to use professional judgment in determining changes in condition based on assessment and findings or signs and symptoms of change which could lead to deterioration if not treated. 3. Clinical change in condition is determined by resident visualization, medical record review, clinical assessment findings and care plan review. Review of high-risk clinical issues such as skin breakdown, falls, weight loss, dehydration and others are conducted on a daily basis. 4. Following the assessment, observing signs and symptoms, and obtaining vital signs, the attending physician, family/guardian will be promptly notified of significant findings. 12. Resident representative(s) notifications and attempts will be made promptly and documented in the nurse's notes. In the event the licensed nurse is unable to contact the resident's representative, after a reasonable time period, the Director of Nursing will be notified. R1's Nursing Note written by V11/Licensed Practical Nurse dated 7/23/25 at 5:29 AM, documents that staff reported discoloration to R1's Left Lower Extremity from the knee down. R1 was guarding and facial grimacing when the leg was touched or moved. The knee was swollen and warm to the touch. No record of a fall. A message was left with Hospice. The Initial Facility Incident Report sent to the (State agency) dated 7/23/25 at 7:00 AM, documents that R1 has diagnoses which include Alzheimer's Disease with Late Onset, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Generalized Anxiety Disorder, Hyperlipidemia, and Delusional Disorder. R1 has confusion regarding time/place/person. Brief Interview of Mental Status 2/15 (severer cognitive impairment). R1 was noted with discoloration and swelling to the Left Lower Extremity. R1 noted guarded and unwilling or unable to extend her leg fully. R1's Family/Resident Representative was notified on 7/23/25 at 11:00 AM. On 8/4/25 at 5:50 PM, V17/R1's Power of Attorney/POA stated that (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 08/06/2025 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)