Inspection visit
Inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to provide 4 out 4 (R25, R179, R180, R181)
residents, Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage and/or the Notice of
Medicare Non-Coverage, (NOMNC), forms during discharge from Medicare A services.
Residents Affected - Some
findings include:
1.)
R25's face sheet documents admission date 0f 12/29/2022. R25's Skilled Nursing Facility Beneficiary
Protection Review document states R25 began skilled Medicare A services on 2/14/2023 and facility
provider initiated the discharge for Medicare part A services when benefit days were not exhausted with
last covered day of Medicare A services to end on 4/28/2023. Facility provided document, titled Notice of
Medicare Non-Coverage, (NOMNC), form for R25 that is not dated, nor is it signed by R25 or her
representative.
On 10/25/2023 at 1:11 PM, V1 (Administrator) stated the facility filled out the forms, but has no proof R25
received the ABN/NONMC forms.
2.)
R179's face sheet documents admission date of 4/14/20223. R179 's Skilled Nursing Facility Beneficiary
Protection Review document states R179 began skilled Medicare A services on 4/14/2023 with voluntary
discharge of last covered day of Medicare A services to end on 7/20/2023. This document states that facility
provided R179 with Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage form. Facility
provided Notice of Medicare Non-Coverage, (NOMNC), form.
On 10/25/2023 at 1:11 PM, V1 stated, We should have given (R179) the SNF/ABN form, but didn't.
3.)
R181's face sheet documents admission date of 4/26/2023 with Medicare A as payor. R181's Skilled
Nursing Facility Beneficiary Protection Review document states R181 began skilled Medicare A services on
4/26/2023 with voluntary discharge of last covered day of Medicare A services to end on 5/12/2023.
On 10/25/2023 at 1:11 PM, V1 stated they have no SNF/ABN/NONMC documents for R181's discharge.
(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 10
Event ID:
145478
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
145478
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Nokomis Hc & Senior Living
505 Stevens Street
Nokomis, IL 62075
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 0582
4.)
Level of Harm - Minimal harm
or potential for actual harm
R180's face sheet documents admission date of 5/12/2023 with Medicare A as payor with discharge date of
6/2/2023.
Residents Affected - Some
On 10/25/2023 at 1:11 PM, V1 stated the facility has no documents for discharge of R180, including no
SNF/AB/NONMC forms.
On 10/25/2023 at 1:11 PM, V1 stated the Skilled Nursing Facility Advanced Beneficiary Notice of
Non-coverage and or the Notice of Medicare Non-Coverage, (NOMNC) forms were not done correctly for
R2r, R179, R180, and R181.
On 10/26/2023 at 10:00 AM, V1 stated the facility does not have a policy on SNF/ABN/NONMC.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145478
If continuation sheet
Page 2 of 10
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
145478
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Nokomis Hc & Senior Living
505 Stevens Street
Nokomis, IL 62075
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 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to transmit MDS, (Minimum Data Set), within 28
days of Assessment Reference Date (ARD) for 4 of 4 (R18, R21, R24, R27) in a sample of 30 residents
reviewed for timely submission of quarterly review assessments.
Residents Affected - Some
findings include:
1.) R18's MDS documents Quarterly Review Assessment, dated 9/13/2023, was signed as complete on
10/22/2023, with a submission date of 10/26/2023.
2.) R21's MDS documents Quarterly Review Assessment, dated 9/8/2023, was signed as complete on
10/3/2023, with a transmission date of 10/26/2023.
3.) R24's MDS documents Quarterly Review Assessment, dated 9/6/2023, was signed as complete on
10/3/2023, with a transmission date of 10/26/2023.
4.) R27's MDS documents Quarterly Review Assessment, dated 9/6/2023, was signed as complete on
10/3/2023, with a transmission date of 10/26/2023.
On 10/25/2023 at 3:00 PM,V13 (MDS coordinator) stated she probably made a mistake and didn't transmit
the MDS timely because she got confused, because there were computer issues.
On 10/26/2023, V1 (Administrator) stated she expects the MDS coordinator to transmit the MDS timely.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145478
If continuation sheet
Page 3 of 10
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
145478
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Nokomis Hc & Senior Living
505 Stevens Street
Nokomis, IL 62075
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
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Actual harm
Based on interview and record review, the Facility failed to collect a Urinalysis in a timely fashion, causing a
delay in treatment for Extended-Spectrum Beta Lactamases, (ESBL), which is an infection requiring contact
isolation, for 1 of 16 residents (R16) reviewed for Quality of Care in the sample of 30.
Residents Affected - Few
Findings include:
R16's Face Sheet, dated 10/24/2023, documents R16 has Chronic Kidney Disease.
R16's Physician's Orders, dated 9/2/2023, documents, Get UA, (Urinalysis), with CNS, (Culture and
Sensitivity), next lab day.
R16's Progress Notes do not indicate a reason for the order, or attempts to obtain the UA.
R16's Lab Report documents a UA was collected on 9/12/2023, and the specimen was cloudy, contained
blood, bacteria and mucous, all of which are abnormal results.
R16's Culture reported to the Facility 9/16/2023 documents R16's culture was positive for >100,000
CFU, (Colony Forming Units) per milliliter of Extended-Spectrum Beta Lactamases, (ESBL), which is an
infection requiring contact isolation.
The Infection Surveillance Monthly Report, dated 10/23/2023, documents R16's infection onset was
9/16/2023, and an order was received to begin an injectable antibiotic.
R16's Medication Administration Record, (MAR), documents, Ertapenem Sodium Injection Solution
Reconstituted, 1 GM, (Gram), -Inject, 1 gram intramuscularly, one time a day for UTI, (Urinary Tract
Infection) for 6 Days, Use Lidocaine, (numbing agent), 1% Injectable solution 3.2 ml to reconstitute. It
further documents, 9 on 9/18/2023.
R16's Physician's Orders, dated 9/16/2023, documents, Contact isolation for ESBL in urine.
On 10/24/2023 at 1:10 PM while being provided peri-care, R16 became upset and was crying. At this time,
V9, Certified Nursing Assistant, (CNA), stated, She probably thinks were are going to mess with her heel,
(change her pressure ulcer dressing), or give her a shot (the Intra-muscular antibiotic injection).
On 10/25/23 at 3:29 PM, V2, Regional Director of Nursing, stated, A lab specimen should be collected as
soon as they can, within a couple days-definitely within 72 hours. She was probably symptomatic and that
is why they collected it.
On 10/26/2023 at 10:47 AM, V11, Licensed Practical Nurse, (LPN), stated she took the order for the UA
and culture to be completed because, (R16's) urine smelled really bad. She was also, more aggressive and
agitated. I don't know if they tried to straight Cath, (cathaterize), her. V11 also stated the Facility's labs are
picked up every Tuesday.
On 10/26/2023 at 11:47 AM, V2 stated she started R16's antibiotic from the C-box, (convenience box), and
it contains only one dose. V2 stated, the 9 on the MAR means 'See Progress Notes'. V2 stated,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145478
If continuation sheet
Page 4 of 10
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
145478
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Nokomis Hc & Senior Living
505 Stevens Street
Nokomis, IL 62075
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
the 2 on the MAR indicates resident refusal.
Level of Harm - Actual harm
R16's Progress Notes, dated 8/18/2023, documents the Pharmacy did not bring the antibiotic, Pharmacy
was called, and the Doctor was notified, for new orders. R16's Progress Notes does not document, any new
orders were received. R16's Progress Notes do not document if the Doctor was notified, or of R16's refusal
of the medication.
Residents Affected - Few
On 10/26/23 at 1:30 PM, V2 stated, (V11) text the Doctor on her personal phone and the Doctor just
replied, Thank-you.
The Facility's Laboratory Tests policy, dated 9/27/2023, documents, Appropriate laboratory monitoring of
disease processes and medication requires consideration of many factors including concomitant disease(s)
and medication(s), wishes of the residents and family and current standards of practice. It further
documents, Laboratory testing will be completed in collaboration with Medicare guidelines, Pharmacy
recommendations and Physician Orders. Obtain laboratory orders upon admission, readmission and PRN,
(as needed), medication and condition monitoring per the Physician's Order.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145478
If continuation sheet
Page 5 of 10
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
145478
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Nokomis Hc & Senior Living
505 Stevens Street
Nokomis, IL 62075
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the Facility failed to prevent the development and worsening of
pressure ulcers as well as implement Physicians Orders and Care Plan interventions for 1 of 2 residents
(R16) reviewed for pressure ulcers in the sample of 30.
Residents Affected - Few
Findings include:
R16's Face Sheet, dated 10/24/2023, documents R16 has a open wound to R16's left foot.
R16's Minimum Data Set (MDS), dated [DATE], documents R16 is totally dependent on staff for bed
mobility.
The Facility's Weekly Wound Tracking documents R16's left heel pressure ulcer was acquired on 8/11/2023
and was 1.5 centimeters (cm) by 2 cm.
R16's Skin Evaluation, dated 10/17/2023, documents R16's left heel pressure ulcer measured 2.5 cm by
3.1 cm, indicating R16's wound has grown in size.
R16's Care Plan, dated 2/24/2023, documents R16 is at risk for pressure ulcers. R16's Care Plan was
updated on 8/11/2023, and an intervention to always wear heel protectors when in bed due to a stage 2
pressure ulcer to R16's left heel.
R16's Order Summary Report, dated 10/24/2023, documents, Heel protectors on at all times while in bed.
On 10/23/23 at 10:25 AM, R16 was sitting in her recliner with the footrest elevated. Both of R16's heels
were resting on the foot of the recliner.
On 10/23/2023 at 1:44 PM, R16 was lying in bed. Neither of R16's feet had heel protectors on.
On 10/24/2023 at 9:30 AM, R16 was lying in bed without heel protectors on either foot. One of the heel
protectors was located on top of the light fixture above R16's bed, and the other one was located in the
empty bed across the room.
On 10/24/2023 at 10:10 AM, V9, Certified Nursing Assistant (CNA) removed R16's sock to show the
surveyor R16's bandage to her left heel. V9 then reapplied the sock, covered R16 up with a blanket, and left
the room without applying R16's heel protectors.
On 10/24/2023 at 11:19 AM, R16 remained in bed without either heel protectors on.
On 10/25/2023 at 3:29 PM, V2, Regional Director of Nursing, stated R16 acquired the pressure ulcer to her
left heel 8/11/23 while at the Facility. V2 stated R16 is supposed to wear both booties and (R16) should
definitely have one on her left heel.
On 10/26/2023 at 10:30 AM, R16 was lying in her bed, without either heel protectors on.
On 10/26/2023 at 1:50 PM, R16 was lying in her bed, without either heel protector on. One heel
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145478
If continuation sheet
Page 6 of 10
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
145478
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Nokomis Hc & Senior Living
505 Stevens Street
Nokomis, IL 62075
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
protector remained on top of the light fixure and the other one was located under a blanket in R16's
recliner.
The Facility's Decubitis Care/Pressure Areas Policy, dated 1/2018, documents, It is the policy of this facility
to ensure a proper treatment program has been instituted and is being closely monitored to promote the
healing of any pressure ulcer. It continues to document, When a pressure ulcer is identified additional
interventions must be established and noted on the care plan in an effort to prevent worsening or
re-occurring pressure ulcers.
Event ID:
Facility ID:
145478
If continuation sheet
Page 7 of 10
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
145478
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Nokomis Hc & Senior Living
505 Stevens Street
Nokomis, IL 62075
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 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on interview and record review, the facility failed to provide the services of a Registered Nurse, for 8
consecutive hours, 7 days a week. this deficient practice has the potential to affect all 27 residents residing
in the facility.
findings include:
On 10/24/23 at 2:32 PM, Nursing Schedules reviewed with noted dates of 9/2/2023, 9/3/2023, 9/9/2023,
9/10/2023, 9/16/2023, 9/17/2023, 9/24/2023, 9/30/2023, 10/15/2023, 10/21/2023 and 10/22/2023, with no
RN scheduled.
On 10/24/2023 at 9:43 AM, V2 (Director of Nursing) stated the facility is having a hard time staffing RNs on
the weekend.
On 10/24/2023 at 9:43 AM, V1 (Administrator) stated they have a DON, but have a hard time getting RNs to
work the weekends, and currently resident census is 27.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145478
If continuation sheet
Page 8 of 10
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
145478
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Nokomis Hc & Senior Living
505 Stevens Street
Nokomis, IL 62075
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 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to complete a performance review of Certified
Nursing Assistant at least once every 12 months. This deficient practice has the potential to affect all 27
residents residing in the facility.
Residents Affected - Many
findings include:
On 10/25/2023 at 2:00 PM, employee file for V8 reviewed, with no documentation of annual performance
evaluations completed.
On 10/25/2023 at 2:00 PM, employee file for V10 reviewed, with no documentation of annual performance
evaluations completed.
On 10/25/2023 at 2:00 PM, employee file for V14 reviewed, with no documentation of annual performance
evaluations completed.
On 10/24/2023 at 9:43 AM, V2 (Director of Nursing) stated if needed, the facility will do competency training
for CNAs, but they do not do annual performance reviews. V2 stated she does not have any employee
records of performance or competency reviews.
On 10/23/2023 at 9:00 AM, V1 (Administrator) stated census is 27.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145478
If continuation sheet
Page 9 of 10
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
145478
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Nokomis Hc & Senior Living
505 Stevens Street
Nokomis, IL 62075
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review, the Facility failed to ensure medications requiring
refrigeration were kept at an acceptable temperature for 9 of 9 residents (R1, R7, R8, R9, R10, R12, R18,
R19, R26), reviewed for medication storage in the sample of 30.
Findings include:
On 10/24/23 at 10:25 AM upon entering the medication room, the door to the refrigerator, which stores
medication, was open. V5, Licensed Practical Nurse (LPN), closed the door at this time. There was a paper
hung up on the door titled Refrigerator Temperature Log: October 2023. This documents no temperature
was taken on 10/4/2023, 10/5/2023, 10/9/2023, and 10/15/2023. It further documents the temperature on
10/13/2023 was 60 degrees (Fahrenheit). The thermometer inside the refrigerator was 62 degrees. V5
stated the night shift is responsible for taking and documenting the temperatures. V5 also stated the
refrigerator door had probably been open since she got supplies out of it sometime earlier in the morning.
On 10/25/2023 at 3:28 PM, V2, Regional Director of Nursing, stated the temperature of the refrigerator
should not be above 40 degrees. When V2 was informed of the temperature she stated, We will have to call
pharmacy to see what we need to get rid of.
On 10/24/2023 at 9:13 AM, V2 stated all unopened insulin should be refrigerated and all the insulin
dependent residents could have been affected.
The Facility provided a document titled, Insulin Dependent Residents. The document listed 9 residents (R1,
R7, R8, R9, R10, R12, R18, R19, R26).
The Facility's Procurement and Storage of Medications, dated 11/6/2018, documents, 11. Medications
requiring refrigeration are to be kept in the locked refrigerator, or in a refrigerator in the locked area. The
Policy does not address the temperature requirements.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145478
If continuation sheet
Page 10 of 10
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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.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
FAQ · About this visit
Common questions about this visit
What happened during the October 26, 2023 survey of NOKOMIS HC & SENIOR LIVING?
This was a inspection survey of NOKOMIS HC & SENIOR LIVING on October 26, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at NOKOMIS HC & SENIOR LIVING on October 26, 2023?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered."
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.