Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R33's face
sheet, dated 02/27/25 documents an admission date of 12/18/24 with diagnoses of Morbid (severe) obesity,
Type 2 diabetes mellitus, chronic kidney disease, local infection of the skin and subcutaneous tissue,
neuromuscular dysfunction of bladder, and acute cystitis with hematuria.
Residents Affected - Some
R33's MDS (Minimum Data Set) dated 02/04/25 documents a BIMS ( Brief Interview for Mental Status)
score of 12 which indicates that R33 has moderately impaired cognition. Section GG documents dependent
with toileting. Section H documents indwelling catheter. Section M documents unhealed pressure
ulcers/injuries as 1 Stage 4.
R33's Care Plan dated 12/20/24 documents a problem area of: R33 (resident) has indwelling urinary
catheter, neuromuscular dysfunction of bladder. Another focus area of: R33 (resident) is at risk for skin
breakdown or pressure ulcers related to decreased mobility, requires assist with mobility, hx (history) ulcers,
obesity, hx masd (moisture associated skin damage) below breast, hx neoplasm breast, ulcer left butt, skin
tear rt (right) butt.
On 02/26/25 at 1:10PM, R33's room was observed to have no enhanced barrier precaution signage on the
door and no PPE (Personal Protective Equipment) accessible around the room.
On 02/26/25 at 1:15PM, V6 (Licensed Practical Nurse/LPN) went into R33's room to perform indwelling
catheter care. V6 washed her hands and applied gloves before performing care. V6 cleansed area around
indwelling catheter insertion site with a warm washcloth and peri wash. V6 then got a new washcloth with
peri wash and then held the indwelling catheter to secure it while V6 started wiping from insertion site down
tube. V6 then removed her gloves and washed hands she then applied a new pair of gloves and cleansed
areas with plain water and then patted the areas dry. V6 then cleaned up her work area she then removed
gloves and performed hand hygiene. V6 then pulled R33's covers back up. V6 did not wear a gown while
providing care to R33.
On 02/26/25 at 1:30PM, V6 stated R33 is not on enhanced barrier precautions. V6 said R33 should be on
enhanced barrier precautions, because R33 has a indwelling catheter and has a pressure ulcer. V6 stated
any resident who has a indwelling catheter, wound, gastrostomy tube or trach should be on enhanced
barrier precautions. V6 stated if R33 was on enhanced barrier precautions she would have donned a gown
as well before providing indwelling catheter care.
4. R15's face sheet documents an admission date of 11/03/2014, with diagnoses in part, aphasia following
cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side,
Contracture, right wrist, Pulmonary fibrosis, flaccid hemiplegia affecting right dominant side, Contracture,
right foot, Contracture of muscle, multiple sites, and Polyosteoarthritis.
(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 4
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
02/27/2025
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)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
R15's MDS dated [DATE], documents a BIMS score of 11, indicating R15 is moderately cognitively
impaired. Section GG documents R15 is dependent with most Activities of Daily Living (ADL) functions.
Section H Bladder and Bowel documents R15 is always incontinent of Bowel and Bladder.
On 02/24/25 at 10:45am, R15's family member stated that she has had a Urinary Tract Infection a while
back, but she seems to be doing better.
On 02/26/25 at 10:38am, incontinence care was performed by V8 (Certified Nursing Assistant/CNA) on
R15, assisted by V9 (CNA). Hand hygiene was performed by V8 and V9, the curtain was pulled to allow
privacy, and applied gloves. V8 began providing peri care, changing to a clean cloth each time she moved
to a new area, no glove changes or hand hygiene was observed. V8 grabbed the top of R15's sheet with
dirty gloves and pulled it up to R15's chest. V8 then pulled the sheet back down and V8 and V9 turned R15
on her side. V8 washed R15's buttocks wearing the same gloves, turned her back over and pulled the sheet
back up to R15's chest. V8 then gathered her supplies and took them to the resident's bathroom. No glove
changes or hand hygiene was performed throughout the course of this observation.
On 2/26/25 at 10:58am, V8 (CNA) stated she wasn't sure about glove changes, she asked if she could
double glove.
5. R31's face sheet documents an admission date of 11/29/2024, with diagnoses in part, Lymphedema, not
elsewhere classified, non-pressure chronic ulcer of unspecified part of left lower leg with fat layer exposed,
non-pressure chronic ulcer of unspecified part of right lower leg with fat layer exposed.
R31's MDS dated [DATE], documents a BIMS score of 15, indicating R15 is cognitively intact.
R31's current Care Plan documents the following problem area with a start date of 11/05/24; Resident has
hx (history) of cellulitis ble (bilateral lower extremities), and current cellulitis.
R31's Physician order report dated 01/27/25-02/27/25 documents the following treatment order with a start
date of 11/01/24. Cleanse BLE (Bilateral Lower Extremities) with soap and water, pat dry, paint legs with
betadine, apply maxorb to open areas, cover with gauze, wrap with kerlix and secure with ace wraps daily.
On 02/24/25 at 10:33am, R31 stated staff will get onto him for not putting his feet up but he can't get into
his recliner to do it. R31 stated he has had cellulitis in his legs, and they have been actively weeping for a
while now and it is still actively weeping.
On 02/24/25 at 10:33am, R31 had wraps on both lower extremities, there was no enhanced barrier
precautions (EBP) or personal protective equipment (PPE) in place on or near R31's door.
On 2/26/25 at 1:41 PM, V3 (LPN/Infection Control Nurse) stated, EBP should be implemented for any
resident that has any tracheostomy, indwelling catheters, wounds, or any open areas.
Based on observation, interview, and record review the facility failed to implement Enhanced Barrier
Precautions (EBP) and Standard Precautions for 5 (R35, R319, R33, R15, and R31) of 9 residents
reviewed for Infection Control in a sample of 43.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145247
If continuation sheet
Page 2 of 4
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
02/27/2025
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)
F 0880
Findings include:
Level of Harm - Minimal harm
or potential for actual harm
The facility policy titled Isolation Precautions/ Enhanced Barrier Precautions (EBP) dated 4/1/2024 states
Policy: It is the policy of Helia Healthcare to make every effort to prevent the spread of infection in the
facility. Standard Precautions require the health care worker (HCW) to estimate the degree of risk
associated with a given task and plan for appropriate personal protective equipment. Enhanced Barrier
Precautions (EBP) is used in combination with Standard Precautions and expand the use of Personal
Protective Equipment (PPE) to donning of gown and gloves during high contact resident care activities that
provide opportunities for transfer of MDROs (Multi Drug Resistant Organisms) to staff hands and clothing.
EBP will be used for any resident who meets the following criteria: infection or colonization with a
CDC-targeted MDRO when Contact Precautions do not otherwise apply; chronic wounds, such as, central
lines, urinary catheters, feeding tubes, and tracheostomies; or indwelling medical devices, such as, central
lines, urinary catheters, feeding tubes, and tracheostomies. Residents who meet the above criteria, EBP
are recommended when performing the following high-contact resident care activities: dressing, providing
hygiene, bathing/showering, transferring, changing linens, changing briefs or assisting with toileting,
indwelling medical devices care or chronic wound care. Place EBP sign at entrance to the room of the
resident who meet criteria.
Residents Affected - Some
1. R35's Active Orders does not contain an order for indwelling urinary catheter prior to 2/27/25. On 2/27/25
Active Orders documents, Indwelling catheter - change catheter and drainage bag monthly and PRN (as
needed).
R35's Nurses Note dated 2/3/25 at 1:58 AM documents, foley cath (catheter) draining yellow.
On 02/24/25 at 10:25 AM, R35 was sitting in his room in a wheelchair with a urinary catheter collection bag
hanging on the underside of wheelchair. No EBP sign was present on R35's door, and there was no
personal protective equipment (PPE) readily available outside of room.
On 2/25/25 at 8:54 AM, there was no EBP signage on the door of R35's room. There was no personal
protective equipment outside of R35's door or any nearby in the hallway within easy access for staff
performing care.
On 2/26/25 at 1:28 PM, V10 (Registered Nurse/RN) entered R35's room to perform catheter care and did
not don a gown. There was no EBP signage on the door of resident's room or PPE easily accessible
outside of R35's room. V10 performed hand hygiene before providing care and then donned gloves. There
was a clean barrier placed on R35's bedside table, and then a bath basin of plain water was placed on the
clean barrier. There was a spray bottle of perineal wash placed on clean barrier. Wash cloths were placed in
the water and a dry towel placed down. V10 picked up the washcloth, sprayed peri wash on the washcloth
and instructed R35 what care she was about to perform. V10 then performed peri care on the surrounding
skin of the perineal area. The washcloth was then placed in a plastic bag. V10 then cleaned the indwelling
catheter tubing from closest to R35 to furthest from R35's body. V10 removed her gloves and performed
hand hygiene. After care was performed V10 stated, EBP should be used for catheter care on any resident
with an indwelling catheter.
2. R319's Active Orders dated 2/20/25 documents, Indwelling catheter- change catheter and drainage bag
PRN as needed.
On 2/24/25 at 10:31 AM, R319 was lying in bed with a urinary catheter drainage bag attached to the frame
of bed with amber colored urine. There was not any EBP signage present on R319's door. There
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145247
If continuation sheet
Page 3 of 4
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
02/27/2025
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)
F 0880
was no personal protective equipment outside of R319's door or easily accessible in the hallway.
Level of Harm - Minimal harm
or potential for actual harm
On 2/26/25 at 10:32 AM, there was no EBP signage present on R319's door and there was no personal
protective equipment near R319's door or easily accessible within hallway. V2, (Director of Nurses/DON)
performed hand hygiene and donned gloves prior to providing care. V2 did not don a gown before
performing wound care on R319's multiple wounds. V2 followed proper hand hygiene and donning of gloves
throughout dressing changes but did not don a gown at any time during the wound care provided.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145247
If continuation sheet
Page 4 of 4
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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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the February 27, 2025 survey of DOCTORS NURSING & REHAB CENTER?
This was a inspection survey of DOCTORS NURSING & REHAB CENTER on February 27, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DOCTORS NURSING & REHAB CENTER on February 27, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.