Inspection visit
Inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to identify a new skin concern for a
resident when it occurred and provide treatments as ordered for 1 of 3 residents (R35) reviewed for
non-pressure related skin concerns in the sample of 21.
Residents Affected - Few
The findings include:
On 2/13/22 at 11:09 AM, R35 was sitting in her wheelchair in her room. R35 did not have any socks on, and
her feet were resting on the floor. R3 had discoloration and swelling to her feet with a sore to her left second
toe. R35 stated the sore to her left foot second toe had been there for at least three days. R35 stated the
nurses are supposed to put skin prep on the top of her big toe every night but it had not been done the last
three nights. R35 stated skin prep was to be applied to any sore on her toes to dry the area out. R35 stated
she has peripheral neuropathy, so it is important to have it done. R35 stated she is supposed to have a
dressing to her left ankle and the last time one was in place was last week. R35 stated she is supposed to
have a dressing to the ankle to protect it. R35 did not have a dressing on her left ankle, the area had a
white spot on it with flaky dry skin.
On 12/14/22 at 11:38 AM, V4 (Licensed Practical Nurse/LPN) stated, R35 has sores on her toes. She has
had them from her shoes rubbing. R35 refuses to keep her shoes off. The sores, they heal up and then they
are rubbed raw again. I haven't seen any sores recently. I haven't been here for a couple of days. No one
has told me about any sores to her toes. I haven't seen them today. She is very good with her own care.
She will let the CNA (Certified Nursing Assistant) know and they will let us know as well if there are any
problems. She was a nurse, and she is alert and oriented. I have not done any treatment to her toes on my
shift. It's not done on my shift. Skin prep might be something she is thinking of that is done to her toes. V4
looked at R35's orders and stated, She has skin prep to the left great toe daily and a foam dressing to her
left ankle. The foam dressing to her ankle is for protection. If the order is in there, then it should be
completed. The foam dressing is done at 9:00 PM and the skin prep is done 6:00 PM - 6:00 AM. R35 also
has an order to apply a wound dressing as needed. It should be documented in progress note if there are
wounds or skin problems. V4 was asked if she would look at R35's feet with the surveyor after the resident
was done with lunch and she agreed.
On 12/14/22 at 1:30 PM, V4 (LPN) stated she went and looked at R35's feet and toes. V4 stated R35 had a
dark area to her left foot second toe so she got an order to apply skin prep to that toe. V4 stated R35
already had an order for skin prep to her left foot great toe that the night shift does to toughen it up. V4
stated she was not sure if R35 had a circulation problem to her feet and that was causing the sores. V4
stated R35 does take her shoes off in her room. V4 stated she just put a progress note in R35's chart about
the wound. V4 stated the progress notes are where any wounds or skin
(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 7
Event ID:
145440
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
145440
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Neighbors Health Center
811 West 2nd
Byron, IL 61010
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
issues are documented and that there wasn't a note in there about the area on her left foot second toe until
she documented it. V4 stated there wasn't any wound documentation for R35. V4 stated the last shower
sheet in R35's chart was dated 11/30/22 and did not show any skin problems. V4 stated for any change in
skin the CNA should notify her right away and it should be marked on the shower sheet. V4 stated she
applied the foam dressing to R35's left ankle because there wasn't one in place but R35 did have a shower
that morning.
The Nurse's Note dated 12/14/22 at 1:11 PM for R35 showed, Scheduled medication given without
difficulty. Resident voiced concern to a visitor that her left second toe is bothering her. Dark area noted to
her left second toe. Resident states her shoes rub on her toes. Resident will take off her shoes while she is
in her room. Skin prep order in place for residents second toe on her left foot. Dressing applied to her left
ankle for protection.
On 12/14/22 at 1:38 PM, V6 (CNA) stated, I have R35 today and I did her shower. I haven't done a shower
sheet yet; I did notice sores on her toes. R35 is always having some issue to her toes. A lot of her toe
injuries come from her wheelchair. When we transfer her to the toilet, she bangs her toe on the wheelchair. I
don't know how long she has had these sores. I had her yesterday, but I didn't look at her skin. I am
supposed to notify nurse about and skin problems. When V6 completed the shower sheet dated 12/14/22
for R35 she marked that the resident had a couple little sores to the toes on her left foot.
On 12/15/22 at 9:49 AM, V2 (Director of Nursing/DON) stated if there are a new skin concerns the CNA's
ideally should notify the nurse ideally as soon as possible. V2 stated staff are supposed to follow the
physician's orders.
The Physician Orders dated 12/14/22 for R35 showed, Apply skin prep to dark areas to left great toe daily;
change foam dressing to left ankle three times per week once a day on Monday, Wednesday and Friday.
Weekly skin check - once a day on Saturday. A new order was added on 12/24/22 to apply skin prep to
darkened area on second toe on her left foot twice a day.
R35's Care Plan dated 11/22/22 showed, R35 is at risk for cardiac complications related to congestive
heart failure .hypertension .peripheral vascular disease Monitor for any signs and symptoms of skin
problems related to peripheral vascular disease: redness, edema, blistering, itching, burning, bruises, cuts,
other skin lesions. R35 is at risk for pressure injury/impaired skin integrity related to weakness, decreased
mobility, peripheral vascular disease, diabetes mellitus and incontinence. There were no interventions in
place related to R35's toes or the dressing to her left ankle.
R35's MDS (Minimum Data Set) dated 11/9/22 showed no cognitive impairment.
R35's Shower Sheets dated 11/30/22 and 12/7/22 did not show any skin problems.
The facility's Management of Wounds policy (10/2022) showed, Our mission is to facilitate resident
independence, promote resident comfort, and preserve dignity. The purpose of this policy is to accomplish
that mission through effective wound management program, allowing our residents a means to receive
necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will
achieve this goal through utilization of the following pertinent aspects: Assessing the resident, which
includes ongoing skin assessment and assessment of risk factors for pressure injury. Assessing the local
wound condition. Determine the etiology. Managing tissue loads. Weekly skin assessment to be done on all
residents weekly by the CNA during the bath. Determine the wound etiology:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145440
If continuation sheet
Page 2 of 7
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
145440
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Neighbors Health Center
811 West 2nd
Byron, IL 61010
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
pressure injuries is a lesion caused by unrelieved pressure that results in damage to underlying tissues.
Diabetic (neuropathic) wounds of the lower extremity are caused by peripheral neuropathy Critical
components of diabetic wound care requires .off-loading the injury site, foot evaluation and orthotic referral
for proper footwear It is the policy of the facility to treat, along with the wound, any conditions that may
contribute to the resident's risk of developing an injury and that may affect functional independence or alter
the healing process.
Event ID:
Facility ID:
145440
If continuation sheet
Page 3 of 7
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
145440
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Neighbors Health Center
811 West 2nd
Byron, IL 61010
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure a resident with swallowing issues was
supervised during meals for 1 of 5 residents (R23) reviewed for safety and supervision in the sample of 21.
The findings include:
R23's face sheet printed on 12/14/22 showed diagnoses including but not limited to dysphagia (difficulty
swallowing food or liquid), pneumonitis due to inhalation of food and vomit, respiratory failure, anxiety, and
protein-calorie malnutrition. R23's facility assessment dated [DATE] showed no severe cognitive impairment
or memory recall problems.
R23's physician order report showed an order for a general, pureed diet started on 11/6/22. The same
report showed an order for droplet/contact isolation due to Herpes Zoster (shingles) started on 11/29/22.
On 12/14/22 at 8:54 AM, R23 was seated in a wheelchair alone in her room and the door was closed. R23
had her breakfast tray in front of her and all foods were a pureed texture. Half of the food had been eaten.
R23 spooned yogurt into her mouth, paused to burp forcefully, and grimaced while swallowing the yogurt.
R23 stated she has esophagus problems and cannot swallow properly. R23 said she eats all meals alone in
her room. Staff bring a tray into her and then close the door because she is on isolation. R23 said she has
choked on her food in the past and had surgery to try to fix the issue, but it still is a problem.
On 12/14/22 at 9:30 AM, V8 (Licensed Practical Nurse/LPN) stated R23 has a swallow issue and needs
pureed foods. She doesn't like it but needs it for safety reasons.
On 12/15/22 at 8:52 AM, R23 was again in her room alone with the door closed. A tray of pureed breakfast
foods was on the table in front of her. At 8:55 AM, V10 (Certified Nurse Aide) said R23 came back from the
hospital with a pureed diet order. V10 said an evaluation was done and it was decided she needed it for
swallowing issues.
On 12/15/22 at 9:40 AM, V9 (Nurse Practitioner) stated R23 has a medical issue with her esophagus, and it
makes it hard for her to swallow. R23 has a history of aspiration pneumonia. She needs to use a swallow
technique to burb between each bite, so she swallows correctly. She is a high risk for choking issues.
On 12/15/22 at 10:23 AM, V13 (LPN) stated anyone with swallow issues needs be sitting upright and eat
with supervision. They need to be watched to ensure they don't choke while eating. Residents with
dysphagia have a hard time swallowing and need supervision during meals.
On 12/15/22 at 10:31 AM, V2 (Director of Nurses) stated residents with swallow issues need monitoring
while eating. Anyone with a puree diet order has a high risk of choking and should always be supervised. If
they are not supervised during meals, there is a big risk for choking or aspiration.
The facility's undated Supervision of Resident Nutrition policy states: 5. Residents needing assistance in
eating must be out in a supervised area or should be supervised if eating in their room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145440
If continuation sheet
Page 4 of 7
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
145440
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Neighbors Health Center
811 West 2nd
Byron, IL 61010
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on observation, interview, and record review the facility failed to ensure a resident's indwelling
urinary catheter tubing was secured, not on the floor, or obstructed for 1 of 2 residents (R62) reviewed for
catheters in the sample of 21.
The findings include:
On 12/13/22 at 10:18 AM, R62 was sitting in a recliner in her room. R62 had an offloading boot on her right
lower extremity. R62's catheter tubing was on the floor and her right foot with the offloading boot was laying
on top of the tubing. R2's urine looked cloudy and there was sediment in the tubing. R62 moved her blanket
over on her lap to show the catheter tubing and she did not have a catheter tubing stabilization device in
place. R62 stated she had a shower, and another stabilization device was not applied.
On 12/14/22 at 11:38 AM, V4 (Licensed Practical Nurse/LPN) stated catheter tubing should be on the bed
rail or the bend of R62's chair and shouldn't be on floor for infection control. V4 stated the catheter tubing
should not be occluded in any way. V4 stated catheter secure devices are supposed to be used. V4 stated
R62 has multiple sclerosis and cannot feel when the tubing is pulling too much and then the catheter will
come out with the bulb intact.
On 12/15/22 at 9:49 AM, V2 (Director of Nursing/DON) stated catheter tubing should be positioned so urine
can flow freely into the collection bag. V2 stated the patency of the tubing needs to be maintained so there
isn't a backup of urine which can cause an infection. V2 stated the catheter tubing should not be on the
floor for infection control reasons.
The Face Sheet dated 12/14/22 for R62 showed diagnoses including multiple sclerosis, neuromuscular
dysfunction of the bladder, urinary tract infection, enterocolitis due to clostridium difficile, hypertension and
muscle weakness.
R62's Physician Orders dated 12/14/22 showed indwelling urinary catheter - diagnosis of neurogenic
bladder; catheter care every shift and as needed; catheter stabilization device - monitor every shift to
ensure this in place.
R62's Care Plan dated 9/27/22 showed, R62 requires an indwelling urinary catheter due to neuromuscular
dysfunction related to multiple sclerosis. Avoid lying on top of tubing. Avoid obstructions in the drainage.
The facility's Urinary Catheter Insertion & Maintenance policy (10/2022) showed, Adequately secure and
anchor the catheter to prevent urethral and bladder-neck tension. Catheter stabilization devices should be
in place and changed as needed when soiled or if the integrity of the device is compromised. Ensure that
urine drainage is unobstructed and continuous by avoiding dependent loops, ensuring no kinks in tubing
and bag is positioned below the bladder but not on the floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145440
If continuation sheet
Page 5 of 7
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
145440
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Neighbors Health Center
811 West 2nd
Byron, IL 61010
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to perform hand hygiene during a dressing
change and failed to prevent cross contamination of resident contact surfaces by not removing gloves and
washing hands after providing care for 3 of 10 residents (R33, R12, & R65) reviewed for infection control in
the sample of 21.
Residents Affected - Few
The findings include:
1. On 12/13/22 at 10:42 AM, R65 was laying on her back in a bariatric bed in her room. V5 (Certified
Nursing Assistant/CNA), V6 CNA and V7 CNA were at bedside to clean the resident and provide
incontinence care. V5-V7 had gloves on. V5 took a washcloth and washed R65's armpits and under her
breasts. V5 took a towel and dried R65's armpits and under her breasts. V5 washed and dried R65's
abdomen. V5 took a washcloth and wiped R65's groin from right to left and across the pubis area. V5
washed R65's vaginal area. V5 took a towel and dried R65's groin and vaginal area. V5 did not remove her
gloves, wash her hands and apply clean gloves. V5 assisted R65 onto her left side and held her leg and
back and V7 wiped off R65's back. V5 walked over to the sink area in R65's room, grabbed a clean
washcloth and towel and handed them to V7. V5 put the dirty linen in a plastic bag and tied it shut. V5
stated, I know I messed up. After I was done washing R65 I should have removed my gloves, washed my
hands, and put new gloves on before touching anything else because of cross contamination.
On 12/15/22 at 9:49 AM, V2 (Director of Nursing/DON) stated the expectation is handwashing will be done
before all peri care and glove donning. Handwashing is performed again when doffing gloves and prior to
touching any clean area/ surfaces. It's important for infection control and cross contamination.
The Face Sheet dated 12/14/22 for R65 showed medical diagnoses including morbid (severe) obesity due
to excess calories, body mass index of 70 or greater, paresthesia of the skin, lymphedema, cellulitis,
supraventricular tachycardia, paroxysmal tachycardia, shortness of breath, and hypoxemia.
The Minimum Data Set (MDS) dated [DATE] for R65 showed total dependence on staff for bed mobility,
toilet use, and bathing ; extensive assistance needed for dressing, and personal hygiene; always
incontinent of bowel and bladder.
The Nurse Practitioner's Note for R65 dated 12/13/22 showed R65 is morbidly obese and admits she is
now dependent for all activities of daily living except eating. R65 is bed bound and incontinent.
The facility's Perineal Care policy (no date) showed, Wash hands and put on disposable gloves. Wash
perineal area with soap and water or perineal cleanser. After cleansing is complete, rinse if necessary, and
then dry the resident by patting skin gently with a clean bath towel. Remove gloves and wash hands.
The facility's Hand Hygiene policy (no date) showed, All personnel will follow our established hand hygiene
procedures to prevent the spread of infection and disease to other personnel, residents, and visitors. Hand
hygiene must be performed under the following conditions: Before and after assisting a resident with
personal care.
2. On 12/15/22 at 10:56 AM, V12 (Registered Nurse) did the dressing change on R12's feet. V12 did
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145440
If continuation sheet
Page 6 of 7
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
145440
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Neighbors Health Center
811 West 2nd
Byron, IL 61010
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 - Few
not perform hand hygiene before putting on clean gloves. V12 removed R12's socks. With the same gloves
and no hand hygiene performed, V12 applied skin prep on the second and third toe per orders. V12 placed
the socks back on R12. V12 removed the used gloves. V12 did not perform any hand hygiene. V12 put a
new set of clean gloves on. V12 removed the current dressing on the left foot. With the same gloves and no
hand hygiene performed, V12 cleaned the wound with Dakin's solution, pulled out a piece of collagen from
her supplies, applied it to the wound, and applied gauze roll to the wound. V12 removed the glove on her
right hand, took a pen out of her pocket, and wrote a date on the dressing. V12 removed the other glove.
V12 did not perform hand hygiene. V12 placed a new pair of gloves and then applied R12's shoes. V12
removed her gloves. No hand hygiene was performed.V12 talked with R12 with her hands on her hips,
gathered her supplies and left the room.
On 12/15/22, at 11:15 AM, V12 stated that she should have either washed her hands or used hand
sanitizer before starting the procedure, before wearing a new set of gloves and after the procedure to
prevent cross contamination and further potential infection.
R12's face sheet showed his current admission to the facility was on 04/27/2021 with diagnoses to include
unspecified dementia, diabetes mellitus, peripheral vascular disease, transient ischemic attack, and kidney
failure. R12's facility assessment dated [DATE] showed he had mild cognitive impairment (BIMS Score 10),
required either set-up or minimum assistance of one staff for Activities of Daily Living (ADL).
3. On 12/13/22, at 12:58 PM, V7 (CNA) and V11 (CNA) put on a pair of clean gloves and transferred R33
from the wheelchair to the bed using a mechanical lift. V7 rolled R33 to his right side and removed the sling
from underneath R33. With the same used gloves, V7 took a clean basin out of the closet. V7 rolled R33 to
his left side. V11 completed the perineal care from her side, removed the dirty incontinence brief and
discarded it into a trash bin. With the same gloves on, V11 took the used basin with water, emptied in the
sink, rinsed it, took R33's dirty cloths, and the garbage bag and left the room. In a few minutes, V11
returned to the room with no gloves on.
On 12/13/22, at 01:20 PM, V11 stated that she did not want to touch R33's soiled cloths with her bare
hands. V11 also stated that she should have discarded her used gloves, washed her hands, wore clean
gloves, and taken the soiled cloths and the garbage.
R33's face sheet showed his current admission to the facility was on 04/29/2020 with diagnoses to include
chronic kidney disease, calculus of gall bladder, major depressive disorder, and unspecified dementia.
R33's facility assessment dated [DATE] showed he had moderate cognitive impairment, required total
assistance of two staff for Activities of Daily Living (ADL).
Facility's policy on Gloves showed that 8. Hand hygiene is necessary when gloves are removed. Facility's
policy on Hand Hygiene showed that 2. Hand hygiene must be . g. before and after . perineal care; j. before
and dressing 3. The use of gloves . hand hygiene. Facility's policy on Perineal care showed that Procedure:
. 3. Wash hands Disposable gloves 6. Remove gloves hands.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145440
If continuation sheet
Page 7 of 7
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Back to topCitations
8 citations 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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0133GeneralS&S Epotential for harm
Install a two-hour-resistant firewall separation.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
FAQ · About this visit
Common questions about this visit
What happened during the December 15, 2022 survey of NEIGHBORS HEALTH CENTER?
This was a inspection survey of NEIGHBORS HEALTH CENTER on December 15, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at NEIGHBORS HEALTH CENTER on December 15, 2022?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.