Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to supervise a resident with impaired cognition while drinking
a hot beverage. This failure resulted in the resident spilling the hot beverage, sustaining burns to her
bilateral thighs and was transferred to hospital for treatment of the same.
This applies to 1 of 3 residents (R1) reviewed for accidents and supervision in the sample of 3.
The findings include:
R1's face sheet showed that R1 was admitted to the facility on [DATE] with multiple diagnoses including
Multiple Sclerosis, Dysarthria and Anarthria, Hereditary Spastic Paraplegia, Muscle Wasting and Atrophy,
Anxiety Disorder, Insomnia, Diseases of Spinal Cord.
R1's quarterly MDS (minimum data set) dated February 28, 2025 showed that R1 was severely impaired in
cognition and required supervision or touching assistance for eating.
Facility Incident logs showed that R1 had a hot liquid burn on March 10, 2025.
Facility discharge records and nurses progress notes showed that R1 was discharged to the hospital to the
burn center on March 13, 2025.
Hospital patient information records showed that R1 was admitted to Burn stepdown unit on March 13,
2025. Hospital Burn Attending Physician history and physical progress note dated March 14, 2025 included
that R1 presents with 5% scald burns: full thickness wounds accounting for 1.5 TBSA [total body surface
area] to bilateral thighs .
Occupational Therapy Assessment at hospital dated March 14, 2025 included that R1 is a [AGE] year old
female with diagnosis of Burn who presents impairments in range of motions, strength, gross motor
coordination, fine motor coordination, bilateral coordination, activity intolerance, safety awareness, balance
motor planning, manual dexterity and self help skills. Performance deficits include difficulty in ADLS
[activities of daily living] including feeding.
Facility Change of Condition progress note dated March 13, 2025 included as follows: Resident has a
second degree wound and blister wound on both thigh that needs attention as resident has been refusing
care .
Assessment for the same showed to send to the hospital for further care.
(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 3
Event ID:
145221
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
145221
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parc Joliet
222 North Hammes
Joliet, IL 60435
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)
F 0689
Level of Harm - Actual harm
Residents Affected - Few
Facility nursing progress notes dated March 10, 2025 included as follows: Resident sitting in hallway across
from nurses station after shower for monitoring at 1515 (3:15 PM) resident yelled out CNA (Certified
Nursing Assistant) went to assist resident noted resident had spilled drinking cup over, CNA took resident
to room to change wet clothing summons this writer to resident room, this writer noted both thighs were
reddened with blistered area on bilateral thighs, wound care nurse informed area addressed per wound
care protocol .
On March 28, 2025 at 9:52 AM, V5 (Licensed Practical Nurse) stated that on March 10, 2025, she was R1's
nurse and V6 (CNA) had brought R1 out to the nurses station after a shower and placed her in a geri
(recliner with wheeled bases) chair and given her something warm to drink. V5 stated that it was around the
change of shift in the afternoon. V5 stated that she believes that V6 had heated up some water with a tea
bag and set it on a bed side table and R1 knocked it off. V5 stated that V6 took R1 to her room to change
her wet clothes and that's when she noticed that the area around R1's upper thighs were reddened. V5
stated that she notified V3 (Wound Care Nurse) and since V3 was leaving for the day, she applied the
treatment based on V3's suggestion and endorsed to the night nurse.
On March 28, 2025 at 2:25 PM, V6 (CNA) stated that she works the afternoon shift on March 10, 2025 and
the routine was that when she comes in she gets her assignments and gives residents their showers. V6
stated that she gave R1 a shower with the assistance of V13 (CNA) and after changing her, they transferred
her to a geri chair and placed her by the nurses station. V6 stated that R1 was cold and asked for tea. V6
continued I made the tea by getting a tea bag from the kitchen and I got water from the faucet and heated
to about 1 to 1 1/2 minutes and gave it to her on a bedside table [that was by the geri-chair]. I had to help
other residents and I walked away to help V13 with the showers. When I was down the hallway in the 2400
unit, she said 'Ahh' and the nurse [V5] told me to check her. I bring her to the room and pulled out her pants
and showed it [reddened area] to the nurse who applied some ointment. She [R1] is always a challenge
and moves around. When asked, what cup she used to heat the water, V6 stated that it was a Styrofoam
disposable cup.
On March 28, 2025 at 10:12 AM, V3 stated that she was working as a floor nurse on March 11, 2025 and
was asked to take a look at R1 while they were providing care. V3 stated Upon laying eyes on her, I can tell
that it had blistered and the skin was pretty exposed. V3 clarified that there was a very large intact blister on
one thigh/leg and on the other thigh/leg the blister was partially ruptured. V3 stated that the staff who were
changing R1 told her that there was a dressing on the partial blistered area but R1 had ripped it off as she
was very agitated which must have caused the blister to be ruptured. V3 also added that lately, the staff had
to assist and cue R1 with eating, more so because of her mental than physical decline.
On March 28,2025 at 12:45 PM, V7 (Restorative Aide) stated that R1 has good and bad days and that on
some days she was able to feed herself and other days the staff provided assistance in eating. V7 added
that R1 had a tendency to lean forward if she was tired or not feeling well.
On March 28, 2025 at 12:47 PM, V8 (CNA) stated that she has taken care of R1 and that for most part, R1
usually ate in the dining room by herself. V8 stated that R1 would sometimes spill food and drinks.
On March 28, 2025 at 2:11 PM, V14 (R1's Power of Attorney) stated You don't give a person hot tea without
a lid knowing her condition. This particular CNA [V6] knows her behavior.
R1's restorative care plan dated January 20, 2023 showed that R1 has a self-care deficit
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145221
If continuation sheet
Page 2 of 3
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
145221
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parc Joliet
222 North Hammes
Joliet, IL 60435
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)
F 0689
(ADLs/Mobility) secondary to her diagnosis of multiple sclerosis and paraplegia. Interventions included
intermittent supervision with meals and encourage to finish food for adequate nutrition, assist as needed.
Level of Harm - Actual harm
Residents Affected - Few
R1's nursing care plan revised January 15, 2023 showed that R1 demonstrates physical & emotional
impairment secondary to neurological disease/damage caused by: multiple sclerosis and paraplegia.
Interventions for the same included to provide assistive/adaptive devices to help the resident do as much
for himself as possible.
R1's behavior care plan initiated April 18, 2024 showed that R1 has potential to demonstrate physical
behaviors or aggressive behaviors towards staff including yelling, knocking stuff down and throwing objects
related to multiple sclerosis. Interventions included to assess and anticipate resident's needs
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145221
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the March 29, 2025 survey of PARC JOLIET?
This was a inspection survey of PARC JOLIET on March 29, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PARC JOLIET on March 29, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.