Health inspection·November 18, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to obtain conduct pre-employment screening, including the Illinois and National Sex Offender Registry, the Illinois Department of Corrections Inmate search, and obtain results of fingerprint checks, to determine if employees had a prior criminal history which would disqualify them for employment. This had the potential to affect all the 36 residents living in the facility. Residents Affected - Many Findings include: The facility's Abuse Prevention Program Policy, dated 11/28/16, documents, This facility affirms the right out of our residents to be free from abuse, neglect, misappropriate of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of our residents. This will be done by conducting required pre-employment screening of employees. The facility's Health Care Worker Background Check Policy and Procedure, dated 2/28/12, documented it is the policy of the facility that all persons employed in the care facility are required to be free of conviction of committing, or attempting to commit any crime listed in the Health Care Worker Background Check Act. The facility will request a background check on all employees. Employees will be terminated if the background check or the results of the Health Care Worker Registry reveal a finding of ineligibility. Persons applying for employment will be hired conditioned upon results of the appropriate background check as follows: A fingerprint based criminal history records check will be required of all individuals applying for a direct care position or having access to long-term care residents or the living quarters or financial, medical or personal records of long-term care residents, hereinafter referred to as Direct Care Applicant. A UCIA non-fingerprint conviction background check will be required of all individuals licensed by the Department of Financial and Professional Regulation or the Department of Public Health under another law of this state, hereafter referred to as Licensed Applicant. It continues, 2. The Administrator/designee confirms the certification of an employee by checking the Health Care Worker Registry. Whether a fingerprint-based criminal history records check has previously been conducted is indicated by the identifier of Fee App or CAAPP. It continues, 5. In all cases, the facility shall conduct internet searches on certain web sites, including without limitation: the Illinois Sex Offender Registry; the Department of Corrections' Sex Offender Search Engine; the Department of Corrections Inmate Search Engine; The Department of Correction Wanted Fugitives Search Engine; the National Sex Offender Registry and the website of the Health and Human Services Office of Inspector General to determine if the applicated has been adjudicated a sex offender, has been a prison inmate, or has committed Medicare of Medicaid fraud. On 11/12/24, ten employee files were reviewed for pre-employment screening. The following was (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 8 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 11/18/2024 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)