Health inspection·November 26, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to ensure residents were provided with hot water in their personal showers and sinks for two of three residents (R2, R3) reviewed for adequate hot water temperatures in the sample of four.Findings include:The facility's Resident Rights policy, dated 12/2016, documents Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; self-determination; privacy and confidentiality; have the facility respond to his or her grievances.The facility's Water Temperatures, Safety of policy, dated 12/2009, documents Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 F, or the maximum allowable temperature per state regulation. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log.The facilities bath, shower/tub policy, dated 2/2018, documents The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The same policy also documents Fill the tub approximately one-half full with warm water, 105 degrees, test the water with a bathroom thermometer or your elbow. If using a shower regulate the temperature and the flow of the water.R2's current Care Plan, dated 9/2/25, documents I prefer to get up at 7:30 a.m.-7:45 a.m. I prefer to have my showers three times weekly.R2's Nursing progress notes, dated 11/16/2025 at 1:17 PM and signed by V20 (Licensed Practical Nurse), documents (R2) refused shower this morning. CNA (unknown Certified Nursing Assistant) checked resident faucet and was cold and resident was given secondary option of going to shower room where there was hot water or staff bring a basin with hot water and wash cloths to her room. (R2) told writer she appreciated that they offered but she already started getting dressed and did not want to take shower today.On 11/24/25 at 11:55 AM, R2 was sitting in her room with family members visiting (V21 and V22). R2 stated she pays for a private room in the facility and has a shower but no longer has hot water. R2 stated It was hot until about two or three weeks ago but now I have no hot water in the bathroom. The water is cold in the shower and the sink. No one has come to talk to me about how long it will be like this. They just say, they're working on it every time I mention it, but no one has given a resolution or an answer as to how long I won't have hot water in my bathroom. I don't want to go through the lobby and the whole building to get a shower, that would be embarrassing. I can do a lot myself and I prefer to shower in my room. At this time, V21 stated that R2 gets her hair done in the salon and the water in there is also very cold. R3's current Care Plan, dated 11/25/25, documents Preferred Routine: I will be allowed routines of my preference that are safe unless I request a change in my preference through review date. I prefer to have my showers three times weekly.On 11/24/25 at 1:39 PM, R3 was in her room sitting on the edge of her bed. R3 stated she does not have any hot water in her bathroom for showers or the sink. R3 stated I should be able to take a shower on my own and staff do not Page 1 of 3 146100 146100 11/26/2025 Cass County Senior Living & Rehabilitation LLC 530 East Beardstown Street Virginia, IL 62691

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few help me. But since it's been cold, I just use the sink and a cold washcloth. I don't know why the water is cold, but I don't want to use the community shower.On 11/24/25 at 10:35 AM, V10 (Certified Nursing Assistant) stated I know the 100-hall has been without hot water for around six months. The 200 and 300 halls could be hit or miss if they have hot water each day, but now they are both also without hot water. It has been an issue that everyone (staff) has known about for a while. Residents in private rooms can't use their showers which has made those residents and their families upset. On 11/24/25 at 10:52 AM, V11 (Certified Nursing Assistant) stated There is no hot water in the 100-hall. I have worked here about three months and there hasn't been any since I started. The 300-hall also is without hot water. The 200-hall had it but has been without for about a month now. Resident showers must be done in the shower room, sometimes those aren't very warm either. (R2) complains about not being able to shower in her room. (R2) refused to go to the shower room and didn't want me to heat her up water the other day, she just used a cold washcloth to get cleaned up at her sink.On 11/24/25 at 11:15 AM, V14 (Certified Nursing Assistant) stated In the two months I have worked here, the facility has been without hot water the whole time. (R2) complains because she can't use the water in her room on the hot setting. The water being cold in resident rooms is not fair to the residents who have private rooms. They are unable to use their shower and need to use the community showers, but many choose not to or don't want to go to that shower, and I don't blame them. This is supposed to be their home, and the issue hasn't been fixed for a long time.On 11/24/25 at 11:30 AM, V5 (Maintenance Director) confirmed the facility is having issues with the hot water. V5 stated Sometimes the water heater works and other times it isn't working. We have had a company in here to fix the water heater. The company was told what parts are needed and I am not able to make the decisions to order or hire the work.On 11/25/25 at 10:50 AM, V5 toured facility and checked multiple temperatures of hot water. After allowing the hot water to run for several minutes, V5 checked the temperature of the facility's Shower Room two and stated it was 90 degrees Fahrenheit (F). V5 confirmed that 90 degrees F, is less than a person's body temperature and is not considered to be hot. During these water temperature checks at 11:00 AM, V5 checked the hot water temperature in R2's bathroom. After allowing the water to run for several minutes, V5 stated the hot water temperature in R2's shower and sink was 65 degrees F. V5 stated That's almost lower than the cold-water temp and that's the hot water setting. At 11:07 AM, V5 checked the hot water temperature in R3's bathroom. After allowing the water to run for several minutes, V5 stated the hot water temperature in R3's shower and sink was 65 degrees F. At this time, V5 confirmed that R2 and R3 showers in their rooms, are not heating at all. V5 stated I understand why residents and families would be upset. This is their home, and it should feel comfortable and be in working order. 146100 Page 2 of 3 146100 11/26/2025 Cass County Senior Living & Rehabilitation LLC 530 East Beardstown Street Virginia, IL 62691

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 ensure a resident with a diagnosis of hemiplegia, was transferred safely to prevent skin tear injury to their affected arm, for one of three residents (R1) reviewed for injury in the sample of four.Findings include:The facility's Safe Lifting and movement of Residents policy, dated 7/2017, documents In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents to reduce the risk of injury where possible. Resident safety, dignity, self-initiated movement during transfer, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.R1's Minimum Data Set assessment, dated 10/16/26, documents R1 requires assistance of one staff to transfer and has an upper body impairment on one side.R1's Care Plan, dated 10/11/25, documents R1 has diagnoses of dizziness, reduced mobility, traumatic hemorrhage of right cerebrum without loss of consciousness, hemiplegia affecting left dominant side, and muscle weakness. This care plan documents Self-care deficit. Assist with ambulation, transfers, and locomotion on and unit as needed. This same care plan also documents Actual alteration in skin integrity. Skin tear times two to left antecubital forearm. Interventions: 10/14/25, (gripped arm covering) to left arm at all times due to risk of skin injury related to left side hemiplegia.R1's New Skin injury form statement, dated 11/7/25 and written by V11 (Certified Nursing Assistant), documents (V12, Licensed Practical Nurse) and I had placed (R1) on the commode. As we assisted her off the commode we did not realize (R2's) left arm had slipped under the armrest of the commode and as we lifted her, her arm stayed under the rail causing skin tears.On 11/24/25 at 10:52 AM, V11 stated When (R1) had her injury to her left arm I was assisting her along with a nurse (V12), to get transferred from the commode to her chair. (R2's) arm that is weaker, was under the commode rest and it got caught as we went to stand her. We realized it right away, but she did have a flap of skin that tore during the transfer. V11 confirmed that R1 had less control over that arm and needed staff to ensure it was in a safe position to avoid it being injured during a transfer. 146100 Page 3 of 3