Health inspection·December 12, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse for 1 of 5 residents (R2) reviewed for abuse in the sample of 6.Findings include:R2's Face sheet documented an admission date of 08/16/2025 to the facility. Diagnoses listed include: chronic atrial fibrillation, congestive heart failure, systemic lupus, osteoporosis, hypotension, gastro-esophageal reflux disease, low back pain, shortness of breath, chronic kidney disease stage 4, and aneurysm of ascending aorta.R2'S Minimum Data Set (MDS) dated [DATE] documented that R2 has a Brief Interview for Mental Status (BIMS) of 14, indicating R2 was cognitively intact.R2's Nurse note documented on 09/15/2025 that a call placed to local police department and physician to inform of abuse allegation. R2's nurse notes do not document anything further regarding R2's allegation of verbal abuse.A form titled State of Illinois Department of Public Health Long - term Care Facility and IID Serious Injury Incident Report dated 09-17-2025, documented this is a final reportable following and initial submitted on 09-15-2025 regarding an alleged abuse investigation. R2 alleged that a certified nurse assistant was being verbally abusive. R2's description of the certified nurse assistant did not match any employee that was scheduled on the days she alleged being abused. The facility was unable to substantiate the alleged abuse. Review of V1's (Administrator) abuse investigation file for R2 documented on 09/17/2025 R2 felt a staff member was not being nice to her. It goes on to document that R2 could recall that the girl had dark curly hair and white skin, and that R2 could not recall what was said. The file contained 18 documents that has staff across the top. Of the 18, 12 of the forms have a staff members name documented on it to indicate who was interviewed / asked the questions on the form. The remaining 6 did not have any identifying factors to know who gave the interview / or who filled out the questionnaire.On 12/11/2025 at 3:13 P.M. R2 stated the day she reported the abuse, the cna was wanting to give her a shower and she did not feel like it. R2 stated she was sick that day and did not want a shower. R2 stated the cna got in her face and stated loudly you are not sick. R2 stated another time she was supposed to wait for someone to walk with her from the bathroom to her bed. R2 stated when she finished using the rest room, she turned the call light on, stood up, cleaned herself, pulled her pants up and sat back down. R2 stated the same cna who yelled in her face came in and stated in a mean tone you haven't even went to the bathroom yet. R2 stated she tried to explain to the cna what she did. R2 stated that someone from the facility must have talked to the cna after she reported her because she stayed away from her for a couple days. R2 stated when the cna came back to work with her she was very nice and kind. R2 stated she is not sure what the outcome was after she reported the alleged abuse. R2 stated she did not know the cna's name, but she knew she had dark, curly hair and her skin was a tan light brown color. R2 stated the cna was not white. R2 stated she knew if she did not report it that it would be worse for her. R2 stated she wished she would have reported it the first time when the bathroom incident happened.On 12/11/2025 at 3:51 P.M., V1 (Administrator) stated she completed the abuse Residents Affected - Few (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: 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 12/12/2025 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)