Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure a resident's representative was notified of a
resident's increase in behaviors, a new skin tear, and bruising for 1 of 3 residents (R1) reviewed for
notification in the sample of 9.
The findings include:
R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Chronic
Obstructive Pulmonary Disease, Urinary Tract Infection, hypothyroidism, hypertension, major depressive
disorder, and asthma. R1's facility assessment dated [DATE] showed she has moderate cognitive
impairment and requires assistance from staff for all cares.
On 9/17/23 at 9:31 AM, V11 (R1's Power of Attorney) said the biggest problem that she has with the facility
is that they don't notify her when R1 is having behaviors. V11 said R1 had an episode that resulted in a skin
tear and bruises. V11 said she had come into the facility for a visit on Sunday (7/23/23) and noticed R1 had
a bandage on her arm and bruises. V11 said she asked the CNAs on duty at that time about it and no one
knew what happened. V11 said she went in and spoke with (V2 Interim Director of Nursing) on Monday and
spoke to her about not being notified that something had happened with R1 and V2 assured her she would
take care of the problem. V11 said another incident happened over this past weekend and no one notified
her until V2 called her on Monday (9/11/23).
R1's 7/21/23 nursing progress note showed, 1930 (7:30 PM) Patient began going in and out of other
patients' rooms, screaming at them to get out of bed. Staff tried to redirect her, and she started hitting and
pinching them. She continued to go up and down hallway yelling and entering rooms. Behavioral Health NP
(Nurse Practitioner) notified with a message, waiting for a reply.
R1's 7/21/23 nursing progress note entered at 10:58 PM showed, Continuing to wait for a response from
Behavioral Health to call back. Patient keeps entering rooms stating that she is supposed to go in and
check on the people and that she doesn't have to listen to anyone but her boss . Patient then went to the
end doors and was banging on them and screaming.
R1's 7/22/23 nursing progress note entered at 3:42 AM showed, No response from behavioral health at this
time. CNA notified this nurse that patient was continuing to go into rooms and yell that they were in her
house. Staff was unable to get patient out of other residents' rooms and patient was yelling and screaming
very loudly. Staff had to remove patient because she wouldn't cooperate and leave other residents' rooms.
Patient was brought off the unit to the desk. She was attempting to bite, kick, hit, and pull hair of staff.
Patient received a skin tear to right forearm during this. Patient
(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 4
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
09/18/2023
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
continued to scream and state she was telling the Sheriff so we couldn't bandage it. Call placed to
telehealth. During waiting period patient continued to be delusional and verbally and physically aggressive
with staff. A call was then made to telehealth by phone. After 20 minutes waiting for return call, another call
was made to telehealth. After 10 minutes a call was received from the on-call MD. A condition update was
given, and new orders received. Patient finally started to calm down and talk to staff about her family. A
snack was given and eventually after several more minutes she agreed to go back to her room and get her
shoes. Patient went to bed with no problem. Patient has a history of these occasional outbursts but very
infrequent.
R1's 7/23/23 10:00 AM nursing note recorded as Late Entry on 7/24/23 at 10:55 AM showed, Niece, POA
here for a visit and she is aware that resident had some behavior issues on Friday night. Niece said in the
future she would like to be called and she would come and sit with her if necessary.
R1's 8/15/23 nursing progress note entered at 8:05 PM showed, Patient was agitated this shift. She was
going into other people's rooms and not wanting to leave them. She was very hard to redirect. (No
notification to the Power of Attorney was documented.)
R1's 9/9/23 nursing progress note entered at 11:33 PM showed, Patient shoving her bed in front of her
bedroom door and refusing to let staff in the room. She appears very agitated and is hard to redirect. She
will keep bothering her roommate and making hard for her to sleep. Patient refuses to come to the dayroom
to watch TV so that her roommate can rest. (No notification to the Power of Attorney was documented.)
R1's 9/11/23 nursing progress note showed, Call placed to resident POA (Power of Attorney) to update
regarding recent behaviors. After speaking with [R1's POA] a request was made for a urinalysis.
On 9/17/23 at 2:30 PM, V8 (Licensed Practical Nurse/LPN) said, . If there are extensive behaviors, we
contact the behavioral health nurse practitioner and POA (Power of Attorney). If they are redirectable then
we don't always make notifications .
On 9/17/23 at 2:54 PM, V10 (LPN) said R1 gets anxious and territorial. V10 said R1 gets worked up and
delusional and becomes hard to redirect. V10 said R1 does not have any PRN (as needed) medications to
be given during these times because these behaviors are usually the result of a UTI (Urinary Tract
Infection). V10 said R1 sustained a skin tear during one of her more recent behavioral outbursts because
she was swinging her arms and punching at the CNAs (Certified Nursing Assistant). V10 said this last time
she did not notify the POA of the behaviors because they happened in the middle of the night.
On 9/18/23 at 12:40 PM, V2 (Interim Director of Nursing) said, I would encourage them to call (to update)
POA because I would air on the side of caution. I can't say if notification needed to be made because I don't
know the situation. R1's POA did express a desire to be notified which is why I touch base with her.
The facility's policy and procedure reviewed 3/2003 showed, Change in Resident's Condition or Status,
Objective: Our facility shall promptly notify the resident, his or her attending physician, and representative of
changes in the resident's condition and/or status. Procedures: . 2. Unless otherwise instructed by the
resident, the nurse will notify the resident's representative when: a: The resident is involved in any accident
or incident including injuries of an unknown source. b. There is a significant change in the resident's
physical, mental or psychosocial status .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145440
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
145440
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/18/2023
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 provide incontinence care in a manner to
prevent cross contamination for 2 of 4 residents (R2, R4) reviewed for incontinence care in the sample of 9.
Residents Affected - Few
The findings include:
1. R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include
hypertensive heart disease, chronic kidney disease, vascular dementia, major depressive disorder,
paroxysmal atrial fibrillation, and osteoarthritis. R2's facility assessment dated [DATE] showed she has
severe cognitive impairment and requires extensive assistance of staff for all cares.
R2's care plan initiated 4/22/23 showed, . Toilet Use: [R2] is incontinent of her B&B (bowel and bladder).
Extensive assist for toileting, peri care, and dependent for changing her lower body clothing .
On 9/17/23 at 12:58 PM, R2 was being assisted to use the bathroom by V4 and V5 (Certified Nurse
Assistants/CNAs). V4 and V5 wheeled R2 into the restroom and donned gloves. V4 and V5 performed a
stand pivot transfer from the wheelchair to the toilet. During the transfer they pulled R2's pants down to sit
her on the toilet. V4 placed her entire gloved hand directly on R2's backside to assist with pivoting her
around to sit onto the toilet. V4 then used those same gloved hands to touch R2's wheelchair handles and
armrests, the drawer pulls to the cabinet in the restroom, a clean towel, the faucet handles, and picked up a
new incontinence brief. V4 wet a part of the towel with water and cleanser. V4 wiped R2's perineal area a
couple of times with the wet end of the towel. V4 then pulled up R2's pants and flushed the toilet. V4 and V5
performed another stand pivot transfer for R2 into the wheelchair. V4 removed the gait belt from around R2
with the gloved hands. V4 and V5 then removed their gloves and exited the restroom without performing
hand hygiene. V4 touched R2's wheelchair handles again, arm rests again, and straightened her clothing
before pushing her wheelchair back into the common area. There were no glove changes or hand hygiene
completed at any time during R2's cares.
2. R4's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dementia
with other behavioral disturbance, muscle wasting and atrophy, muscle weakness, hypertension, irritable
bowel syndrome without diarrhea, and osteoarthritis. R4's facility assessment dated [DATE] showed she
has severe cognitive impairment and requires extensive assistance from staff for all cares.
R4's care plan initiated 1/19/23 showed, ADLs (Activities of Daily Living) Functional Status . Toilet Use: [R4]
is frequently incontinent of bowel and bladder. She is extensive assist for toileting, peri care, and changing
clothing as needed .
On 9/17/23 at 12:36 PM, V5 (CNA) assisted R4 out of the recliner and ambulated her into the bathroom. V5
assisted R4 to pull her pants down and then seated her on the toilet. V5 donned gloves and removed R4's
urine-soaked incontinence brief which also had stool in it. V5 folded up the incontinence brief with her
gloved hands and placed it in the trash bin. V5 then picked up a new incontinence brief with the same
gloves on and placed the brief around R4's legs. V5 touched the faucet handles with the same gloved
hands, turned the water on, grabbed a clean towel and wet the towel under the faucet. V5 picked up the
cleanser bottle and squirted some onto the wet end of the towel. V5 then used the wet end of the towel and
wiped R4's perineal area several times before she folded the towel over
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145440
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
145440
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/18/2023
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
and used it to wipe R4's buttocks. V5 then took a clean dry towel with the same gloves and wiped R4's
perineal area again and then wiped her buttocks. V5 opened the laundry bin and placed the dirty towels into
the bin before she assisted R4 to stand and pull her wet pants back up. V5 then removed the gloves and
immediately ambulated R4 back out of the bathroom into the common area. V5 did not perform hand
hygiene of any kind after the gloves were removed. V5 assisted R4 into the recliner in the common area
and covered her up with a blanket before moving on to assist another resident with repositioning in her
reclining wheelchair.
On 9/17/23 at 2:38 PM, V9 (CNA) said after her gloves get dirty, she should change them because that
would be going from dirty to clean. V9 said hand hygiene should be performed after gloves are removed.
On 9/18/23 at 12:40 PM, V2 (Interim Director of Nursing) said, Hand hygiene should be done before
providing care, after removing gloves, and before putting on a clean brief because we don't want to
contaminate their clean underwear or brief.
The facility's policy and procedure with revision date of 05/17 showed, Gloves; Objective: 1. Gloves must be
worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin.
Procedure: . a. If it is likely that the employee's hands will come in contact with blood, body fluids,
secretions, excretions, mucous membranes and/or non-intact skin while performing the procedure; 8. Hand
hygiene is necessary when gloves are removed .
The facility's policy and procedure with revision date of 05/17 showed, Hand Hygiene; Objective: 1. Hand
hygiene (handwashing or the use of Alcohol Based Hand Rub) is regarded by this organization as the
single most important means of preventing the spread of infections . 1. All personnel will follow our
established hand hygiene procedures to prevent the spread of infection and disease to other personnel,
residents, and visitors . 2. Hand hygiene must be performed under the following conditions: g. Before and
after assisting a resident with personal care; . q. After contact with a resident's blood mucous membranes,
body fluids, excretions, or non-intact skin; . t. After moving gloves . 3. The use of gloves does not replace
hand washing/hand hygiene .
The facility's policy and procedure with revision date of 5/17 showed, Perineal Care; Objective: . 2. To
prevent infection and odors . Procedure: 3. Wash hands and put on disposable gloves 6. Remove gloves
and wash your hands .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145440
If continuation sheet
Page 4 of 4
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Back to topCitations
2 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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
FAQ · About this visit
Common questions about this visit
What happened during the September 18, 2023 survey of NEIGHBORS HEALTH CENTER?
This was a inspection survey of NEIGHBORS HEALTH CENTER on September 18, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at NEIGHBORS HEALTH CENTER on September 18, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.