F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure a dependent residents was provided
showers for 1 of 3 residents (R1) reviewed for activities of daily living in the sample of 7.
Residents Affected - Few
The findings include:
R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include sepsis,
pneumonia, urinary tract infection, seizures, dysphasia, aphasia, peripheral vascular disease, pressure
ulcer of right buttock, incontinence without sensory awareness, irritant contact dermatitis due to fecal,
urinary, or dual incontinence.
R1's facility assessment dated [DATE] showed R1 is dependent upon staff for all cares.
R1's care plan initiated 3/21/2016 showed, [R1] has an ADL (activities of daily living) self-care performance
deficit related to limited mobility and weakness secondary to cardiovascular accident with right hemiplegia
and requires extensive assist with ADL's and dependent on staff for transfers . [R1] requires extensive
assist of 2 staff with bathing/showering per should schedule and as necessary .
On 7/31/24 at 11:30 AM, R1 was in her bed receiving incontinence care from staff. R1's hair appeared dirty
and unkempt. R1's mouth was dry, and she had a thick layer of residue across her teeth.
On 7/31/24 at 11:14 AM, V7 CNA (Certified Nursing Assistant) said showers are done for residents twice a
week and completed on Monday through Friday. V7 said showers are not documented in the electronic
record but are documented on shower sheets.
On 7/31/24 at 11:19 AM, V4 RN (Registered Nurse) said shower sheets are completed by the CNAs, the
nurses sign off on them, and then they are given to her as the Wound Care Nurse to keep records. V4 said
showers are only documented on shower sheets.
On 7/31/24 at 11:21 AM, V4 provided R1's shower sheets for July 2024. There were 2 shower sheets
provided with one dated 7/17/24 showing R1 refused a shower and one 7/24/24 indicated the shower was
completed. There was no evidence found that R1 had more than 1 shower given to her for the month of
July.
On 7/31/24 at 10:34 AM, V8 (Registered Nurse from Day Surgery at local acute care hospital) said R1 had
been to their department on 7/30/24 for a procedure. V8 said when R1 arrived for the procedure she
appeared unkempt, her hair appeared dirty, she was wearing a dirty, foul smelling hospital gown,
(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:
145414
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
145414
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Crossing Lvg & Rehab
409 West Comanche Road
Shabbona, IL 60550
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
and it appeared to have been quite some time since she received oral care because her teeth were
covered in a thick layer of plaque or debris.
On 7/31/24 at V2 DON (Director of Nursing) said she expects residents to receive at least one shower each
week. V2 said the CNAs should offer the shower more than once and if they refuse the nurse should be
notified of the refusal.
The facility's policy and procedure for providing resident care and showers was requested. V1
(Administrator) said the facility does not have a policy regarding providing showers.
The facility's policy and procedure titled Mouth Care showed, . the purposes of this procedure are to keep
the resident' slips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent
infections of the mouth .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145414
If continuation sheet
Page 2 of 2
