F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure resident's advance directives and physician's orders
reflected resident's wishes for 2 of 3 residents (R41 and R58) reviewed for advance directives in a sample
of 25.
Findings include:
1. R41's Face Sheet, with original admission date of [DATE], documents R41 has diagnoses of but not
limited to chronic combined systolic (congestive) and diastolic (congestive) heart failure, chronic obstructive
pulmonary disease with (acute) lower respiratory infection, atherosclerotic heart disease, and chronic atrial
fibrillation.
R41's Minimum Data Set (MDS), dated [DATE], documents R41 is severely cognitively impaired with a Brief
Interview for Mental Status (BIMS) of 06 out of 15 and she is dependent on staff for most of her activities of
daily living (ADLs).
R41's Care Plan, not dated, documents Resident desires CPR be initiated in the event of cardiac arrest,
resident wishes will be honored thru next review, Full Code/CPR, In the event of cardiac arrest, CPR will be
initiated, and continue until EMS arrival to take over compressions, and/or physician gives order to stop
compressions, if not effective, Provide information regarding Advance Directives upon admission.
R41's Physician's Order, dated [DATE], documents R41 was a Full Code, and the order was discontinued
and R41 was made a Do Not Resuscitate (DNR) on [DATE].
R41's Practitioner Order for Life-Sustaining Treatment (POLST), dated [DATE], documents R41's wishes
are to be a DNR.
R41's Updated Care Plan, print date of [DATE], documents R41 desires no life-prolonging measures in the
event of cardiac or respiratory arrest as evidenced by advance directives/POLST form.
2. R58's Face Sheet, with original admission date of [DATE], documents R58 has diagnoses of but not
limited to Parkinson's disease and dementia.
R58's MDS, dated [DATE], documents R58's is severely cognitively impaired and is dependent on staff for
most of his ADLs.
(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:
145367
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
145367
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gillespie Health & Rehab Ctr
7588 Staunton Road
Gillespie, IL 62033
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 0578
R58's Care Plan, with admission date of [DATE], has no documentation of his advanced directive wishes.
Level of Harm - Minimal harm
or potential for actual harm
R58's Physician's Orders, dated [DATE], documents Full Code See POLST for medical interventions.
R58's POLST, dated [DATE], documents R58 wishes to be a DNR.
Residents Affected - Few
[DATE] 12:40 PM V1, Administrator stated the resident's physician's orders will document they are a full
code until the doctor signs the POLST and then V13, Social Services will notify the nurse so the nurse can
change it in the computer and then the nurse will pass it on to the V4, MDS coordinator so she can update
the care plan. She said they must not have notified anyone of the updated POLST so they could change
them in the computer, and they would get them changed right away.
The facility's Advanced Directives policy, issue date of [DATE], documents Purpose: To provide guidance to
staff on the expectation of respecting residents wishes with regards to Advance Directives and compliance
with state and federal regulations. Policy: Advance directives will be respected in accordance with state law
and facility policy. Responsibility: It is the responsibility of the Social Service department/Administrator to
know the regulations/policies and ensure all appropriate staff are aware. Procedure: 1. Upon admission, the
resident will be provided with written information concerning the right to refuse or accept medical or
surgical treatment and to formulate an advance directive if he or she chooses to do so. If further documents
7. Information about whether or not the resident has executed an advance directive shall be prominently in
the medical record. It also states 10. The Plan of Care for each resident will be consistent with his or her
documented treatment preferences and/or advance directives. It further states 20. The Director of Nursing
Services or designee will notify the Attending Physician of advance directives so that appropriate orders
can be documented in the resident's medical records and plan of care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145367
If continuation sheet
Page 2 of 2
