Health inspection·December 12, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 maintain comfortable temperatures in the facility for 9 (R1-R9) residents living in the facility. The facility also failed to maintain ceiling tiles and HVAC (Heating Ventilation and Air Conditioning) Units in a safe and sanitary condition. This failure has the potential to affect all 74 residents residing in the facility. The findings include: 1. On 12/6/24 at 10:12 AM, R1 was lying in bed under 5 blankets with another blanket covering his feet. R2 (R1's) roommate was sitting in his wheelchair in their room dressed and wearing his coat. R2 said it had been really cold in their room and that was why R2 was wearing his coat. V7 (Housekeeping Supervisor) was asked to turn on the heating unit in R1 and R2's room. When V7 pushed the red button on the heating unit a small amount of cold air started blowing out of the heating unit. V7 said she did not know if R1 and R2's heating unit was working. R1 and R2's heating unit did not have a knob to adjust the temperature, only the small metal piece the temperature adjustment knob would connect to. R1 and R2's heating unit did not have any markings around the temperature control knob area to indicate what temperature the heating unit was set on. On 12/6/24 at 11:34 AM, R1 said he had been in his current room a couple of months. R1 said the heat and air unit in his room had not worked since he had moved to that room. R1 said during the summer the facility had provided an air conditioning unit that hooked up to his window. R1 pointed to the window and said, look you can still see the marks left by the tape they used. R1's window had a blackish residue that was slightly tacky to the touch. R1 had 5 blankets on his bed and said, it was terribly cold in here last night. R1's Resident Face Sheet documented an admission date of 5/1/24. R1's Resident Census documented R1 had resided in his current room since 8/27/24. R1 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 8, indicating R1 was moderately cognitively impaired. R2's Resident Face Sheet documented an admission date of 11/26/24. R2's Resident Census documented R2 had resided in his current room since 11/26/24. R2 MDS documented a BIMS score of 9, indicating R2 was moderately cognitively impaired. On 12/6/24 at 10:21 AM, V4 (Housekeeper) went to the maintenance shed and brought back a handheld thermometer gun. V4 shot the thermometer gun towards the wall of R1 and R2's room and said the room temperature was 64.9 degrees Fahrenheit (F). V4 gave the handheld thermometer gun to the surveyor. 2. On 12/6/24 at 10:54 AM, R3 said the heat in his room was not working. R3 said the night before (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 5 Event ID: 145247 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 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881 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)