F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to ensure sufficient seating was
available to accommodate residents who chose to eat in the dining room. This failure affected R1, R4, R6,
R9, R10, R15, R19, R24, R30, R62, R68, R74, R230 and R305 reviewed for resident rights. Findings
include:On 05/27/25 at 12:10 PM, Seven residents, R1, R6, R9, R19, R74, R230 and R305, were sitting in
their wheelchairs at the entrance to the dining room watching other residents seated at dining tables eat
lunch. R230 stated, We (residents) are waiting for a spot to open up so we can eat lunch. It'll be an hour
before we can eat.On 05/27/25 at 12:15 PM, V4 (Certified Nursing Assistant) stated, The residents (R1, R6,
R9, R19, R74, R230 and R305) who are waiting in the front of the dining room must wait to eat. They must
wait until a seat at a table opens up once a resident finishes eating. There are a few that have to wait to eat
because there are not enough seats available for everyone at once.On 05/27/25 at 12:20 PM, V9 (Licensed
Practical Nurse/Staff Educator) stated there are currently not enough seats in the dining room for all the
residents who choose to come to the dining room to eat lunch.On 05/28/25 at 11:45 AM, V10
(Ombudsman) stated, The biggest concern at the facility is the seating in the dining room because there is
not enough space. I often see several residents sitting and waiting around for a seat at a table to open
because all spots at the tables are occupied by other residents.On 05/28/25 at 12:15 PM, R4, R6, R10,
R13, R15, R24, R30, R62 and R68 were sitting in their wheelchairs close to the Nurse's Station near the
entrance to the dining room. V11 (Certified Nursing Assistant) stated, They (R4, R6, R10, R13, R15, R24,
R30, R62 and R68) have to wait for a spot to open up at a table. All the seats in the dining room are full
right now. There are usually a few residents that have to wait because there are just not enough seats.On
05/29/25 at 09:15 AM, R24 was sitting in her wheelchair in her room with her eyes closed. R24 stated, All of
us cannot eat in the dining room at once. There aren't enough seats for everyone, so some of us must sit
and wait if we don't get to the dining room soon enough to secure a seat. The ones who don't get a seat
have to wait an hour before eating, and that sucks.On 05/27/25 at 02:45 PM, V2 (Director of Nursing) stated
that any resident in the facility can come to the dining room to eat, We have some that choose to eat in their
rooms occasionally, but most residents usually come to the dining room to eat.
Residents Affected - Some
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:
145404
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
145404
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Farmington Village Nrsg
701 South Main Street
Farmington, IL 61531
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on Observation, Interview and Record review, the facility failed to thoroughly cleanse around a
wound leaving fecal matter at the exterior boarder of a wound for one of one resident (R72) reviewed for
pressure ulcers in the sample of 37.
Residents Affected - Few
Finding Include:
The facility's Dressing Non-Sterile (Aseptic) policy, dated January 2017, documents, The purpose of this
procedure is to provide guidelines for the application of non-sterile dressings. Clean or irrigate area/wound
with solution specified in treatment order (normal saline, wound cleanser, etc.) Pat peri wound and wound
dry using dry gauze.
R72's Wound Order documents, Cleanse area to sacrum with (wound cleanser), pack wound with wound
cleanser soaked in gauze, cover with ABD (abdominal pad) and secure with tape once daily and as needed
for soiling.
On 5/28/2025 at 9:25 AM, V6 (Wound Nurse) and V8 (CNA/Certified Nursing Assistant) prepared to
perform wound care for R72's sacral pressure ulcer. A pressure wound was present measuring 6.2 cm
(centimeters) wide, 4.5 cm long and 1.5 cm deep. The sacral wound contained grey/black necrotic (dead)
tissue all around the inside of the wound. Yellow slough was noted in areas around the wound and minor
bleeding was noted at the 6-7 o'clock position. At the exterior border of the wound, a round ball of light
brown fecal matter in upper gluteal cleft was present. Without cleansing the fecal matter from the wound
area, V6 and V8 rolled R72 back to her back, replaced the adult brief, and covered R72.
On 5/29/2025 at 9:20 AM, V6 (Wound Nurse) confirmed that she should have cleansed the fecal matter
from the exterior border of the wound.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145404
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
145404
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Farmington Village Nrsg
701 South Main Street
Farmington, IL 61531
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on interview, observation and record review, the facility failed to ensure opened items in the kitchen
were dated when opened and dry food items were stored in an airtight container. These failures have the
potential to affect all 83 residents residing in the facility.
Findings include:
The facility's Storage of Dry Goods/Foods policy (undated) documents, Opened products are labeled,
dated with the use by date and tightly covered to protect against contamination including insects and
rodents. This policy also documents, Plastic containers with tight-fitting lids will be used for storing flour,
sugar, bulk cereal, dried vegetables, etc.
On 05/27/25 at 10:30 AM, a tour of the kitchen was completed with V12 (Dietary Manager). At 10:35 AM in
the dry storage area, the following items were found to be open and were not labeled with the date when
opened: a large bag of yellow cake mix; a large bag of cornbread mix; a large bag of waffle mix; a large bag
of buttermilk biscuits, a large bag of pudding and pie filling; a large bag of graham cracker crumbs; two
bags of strawberry gelatin mix; a bag of lime gelatin mix; and a large bag of batter mix. V12 confirmed none
of these items were dated when opened and stated, We date things the day we receive them, but we've
never dated anything when it gets opened. V12 also confirmed that none of the bags of dry food items were
stored in airtight containers, We just leave everything in the bag that it came in and put a clip on it to keep it
closed.
The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated 05/27/25 and signed by
V1 (Administrator), documents 83 residents are currently residing in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145404
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
145404
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Farmington Village Nrsg
701 South Main Street
Farmington, IL 61531
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
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to implement Enhanced Barrier
Precautions while providing cares to a resident with a central line for one of one resident (R6) reviewed for
Enhanced Barrier Precautions in the sample of 37.
Residents Affected - Few
Findings include:
The facility's Enhanced Barrier Precautions Policy dated 01/2025 documents, Enhanced Barrier
Precautions (EBP) is designed to reduce transmission of Multi-Drug Resistant Organisms (MDROs) and
Extensively Drug-Resistant Organisms (XDROs) in nursing homes. It is the policy of this facility that
Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during
high-contact resident care activities when caring for residents that have an increased risk for acquiring a
MDRO multi-drug resistant organism such as a resident with wounds, indwelling medical devices, or
residents with infection or colonization with a an MDRO or XDRO. Procedure: 1. Standard precautions
should always be applied to all residents at all times. 2. In addition to Standard Precautions residents will be
assessed to determine whether Contact Precautions or Enhanced Barrier Precautions will be implemented.
6. When a resident is actively being treated for an infection if a resident has an XDRO or an MDRO and is
on antibiotics, the resident could be left on Contact Precautions until they are done with the antibiotics and
transition to EBP. 9. Post clear signage on the door/wall outside resident room. a. Type of precautions
(Contact, Droplet, Airborne, or Enhanced Barrier Precautions). 10. Personal protective equipment is
required for all staff providing high-contact resident care activities to include: Dressing, bathing/showering,
transferring, providing hygiene, changing linen, changing briefs, or assisting with toileting, device care or
use: central line, urinary catheter, feeding tube, tracheostomy, or ventilator. 20. Enhanced Barrier
Precautions are intended to be in place for the duration of a resident's stay in the facility or until resolution
of the wound or discontinuation of the indwelling medical device. 21. Person centered care plan will be
developed and placed in resident's EMR (Electronic Medical Record).
R6's Physician's Order dated 5-14-25 documents, Vanco (Vancomycin) one GM (Gram) daily via central
line every 24 hours. Stop date 6-16-25.
R6's current Care Plan documents, I (R6) am receiving (IV/Intravenous) Vancomycin through my central
line due to infection and inflammatory reaction due to my internal joint prosthesis in my left knee. This same
Care Plan does not include an EBP plan of care.
On 5-26-25 at 11:05 AM V5 (Registered Nurse) entered R6's room. V5 applied gloves to both hands. V5 did
not don a gown. V5 proceeded to flush R6's central line to the right chest with normal saline and then
administered Vancomycin one gram at 200 ml (milliliters)/hour. V5 stated during this time, R6 is not in
Enhanced Barrier Precautions.
On 5-28-25 at 3:47 PM V2 (Director of Nursing/DON) stated all residents with central lines should be
placed in Enhanced Barrier Precautions. Staff should apply a gown and gloves when caring for (R6's)
central line.
On 5-29-25 at 9:45 AM V2 (DON) stated, (R6) was never put into Enhanced Barrier Precautions. (R6) does
not have a care plan to include Enhanced Barrier Precautions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145404
If continuation sheet
Page 4 of 4