Inspection visit
Health inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to provide an ambulatory resident with
continuous oxygen (a portable oxygen tank holder).
Residents Affected - Few
This applies to 1 of 1 residents (R76) reviewed for oxygen in a sample of 37.
Findings include:
On 8/27/24 at 10:52 AM, R76 was observed lying in bed wearing 4 liters of oxygen per nasal cannula. R76
said 4 liters was her baseline oxygen setting and what she was wearing at home before coming to facility.
R76 said she is able to walk to the bathroom by herself, but she does not have a way to bring the oxygen
with her to the bathroom. R76 said she has a portable oxygen tank holder on the back of her wheelchair,
but her wheelchair is bariatric and is too wide to fit into the bathroom. R76 said when she has a bowel
movement she requires staff assistance to help wipe and it can take them a long time to come and help her
in the bathroom. R76 said she feels short of breath after a few minutes without her oxygen on while bearing
down for a bowel movement, while waiting for staff assistance, and while pulling her pants up. On 8/28/24 at
2:00 PM, R76 said she needs her oxygen while she is in the bathroom. R76 said being in that small of an
area makes her breathe heavier and she has not been offered a portable oxygen tank holder on wheels.
On 8/28/24 at 1:50 PM, V8 (LPN/Licensed Practical Nurse) said R76 wears continuous 4 liters of oxygen
per nasal cannula and she is able to take herself to the bathroom. V8 said the facility does have portable
oxygen tank holders, but they don't use them because the residents have an oxygen tank holder on the
back of their wheelchairs. V8 said she was aware that R76 had a bariatric wheelchair that it did not fit in the
bathroom. V8 said she knew R76 would go to the bathroom without her oxygen on. V8 said R76 was just
given the okay to go to the bathroom on her own within the past week, and now that the staff is not aware
when R76 is in the bathroom, R76 should be given a portable oxygen tank holder so she can bring her
oxygen with her.
On 8/29/24 at 2:30 PM, V2 (DON/Director of Nursing) said an ambulatory resident with a continuous
oxygen order should be able to go to the bathroom with their oxygen on. V2 said R76 should have been
provided a portable oxygen tank holder for the bathroom because with her chronic respiratory failure she
can experience difficulty breathing and/or her oxygen level could drop if she goes without her oxygen.
R76's Face Sheet shows diagnoses of chronic obstructive pulmonary disease, morbid obesity, and chronic
respiratory failure. R76's MDS (Minimum Data Set) shows her cognition is intact. R76's POS (Physician
Order Sheet) shows an order dated 7/8/24 for 4 liters oxygen per nasal cannula indefinitely related to
chronic respiratory failure. R76's Care Plan dated 7/1/24 shows she has oxygen therapy
(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 21
Event ID:
145538
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
related to respiratory failure and COPD (Chronic Obstructive Pulmonary Disease). Interventions include
oxygen via nasal cannula per doctor's orders.
The facility's policy titled, Oxygen Administration last revised March 2004 states, Purpose: The purpose of
this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a
physician's order for this procedure. Review the physician's orders or the facility's protocol for oxygen
administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3.
Assemble the equipment and supplies as needed . Equipment and Supplies: The following equipment and
supplies will be necessary when performing this procedure. 1. Portable oxygen cylinder (strapped to the
stand) .
Event ID:
Facility ID:
145538
If continuation sheet
Page 2 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 0578
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
Based on interview and record review the facility failed to maintain current and accurate advanced
directives for 2 residents (R69, R115) in a sample of 37.
Residents Affected - Few
Findings include:
On 08/28/24 at 02:03 PM until 02:09 PM, the state surveyor and V2 DON (Director of Nursing) were
conducting a record review for R69 and R115.
1. R69's electronic health record showed 6/21/24 Full Code Status POLST (Physician Orders for Life
Sustaining Treatment) Declaration form, and the Advance Directive book at the nurses' station showed
R69's 2/23/21 DNR (Do Not Resuscitate) form.
2. R115's electronic health record showed a 5/11/24 DNR form and in the Advance Directive book it
showed R115's 2/16/24 Full Code form.
On 08/28/24 02:13 PM V2 (DON) V2 said that both the Advance Directive book and the electronic health
record should be the same because if they are not the facility may not give the right life sustaining
measures that the person wants.
The facility's Advance Directive policy dated November 2016 showed that copies of written advance
directives documents will be filed uploaded in the residence clinical records and for staff not having access
rights to the residents' clinical records the residents' advanced directives is maintained on the nursing unit
and available to staff members for reference to and consideration of in rendering care and services to
residents to whom they are assigned for duty.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 3 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 confined a resident to her bed by placing
interconnected bed bolsters on both sides of the bed and two upper side rails up.
Residents Affected - Few
This applies to 1 of 1 resident (R81) reviewed for physical restraint in a sample of 37.
The findings include:
R81 is a [AGE] year-old female with moderate cognitive impairment as per the Minimum Data Set, dated
[DATE].
On 8/29/24 at 9:45 AM, during wound care with V3 (Assistant Director of Nursing) and V16 (wound care
nurse), R81 was observed with a wedge to her right upper body with both upper side rails up and two
Bolsters to the bottom of bed inter-connected with a strap.
On 8/29/24 at 9:45 AM, V3 (Assistant Director of Nursing / ADON) stated, Those bolsters are
inter-connected with a strap restricting her to get out of bed. It can be a restraint if we don't have a
physician order. We put it there to prevent her fall.
R81's care plan does not indicate any use of bed bolsters planned for resident care (falls).
R81's physician order sheet (POS) for 08/24 does not indicate any physician order for bolsters.
On 08/29/24 at 12:27 PM, V2 (Director of Nursing / DON) stated, There should have been a physician order
for using bolsters and should have been care planned.
The purpose statement of the facility presented physical restraint policy dated 02/2014 document: Restraint
shall not be used for the purpose of punishment or for staff convenience.
A review of the facility-provided physical restraint policy (effective date February 2014)
document:
3. Restraint use data will be provided to the physician for review and prior to ordering/re-ordering restraint
use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 4 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
Based on record review and interview the facility failed to provide written notice of the facility's bed hold
policy to 1 resident (R69) or representative before being transferred to the hospital in a sample of 37.
Residents Affected - Few
Findings include:
On 08/28/24 at 11:46 AM a review of R69's electronic health record showed that on 8/6/24 R69 was sent to
the hospital for labored breathing, oxygen saturation at 86% while on 2 liters of oxygen, a blood pressure of
100/46, and a heart rate of 143. The record review did not show any documentation that R69, or his
representative, received a copy of the facility's bed hold policy.
On 8/29/24 02:14 PM, V2 DON (Director of Nursing) said that the facility did not have any documentation
showing that the resident or representative received the facility's bed hold policy.
On 8/29/24 at 4:06 PM, V2 DON said that it is her expectations that the facility staff provide the resident or
the resident's representative, the facility's bed hold policy when they are being transferred to the hospital.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 5 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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
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 provide hygiene care and maintenance.
Residents Affected - Some
This applies to 4 of 6 residents reviewed for ADL (Activities of Daily Living) in a sample of 37.
Findings include:
1.
R65 admitted to the facility on [DATE] with diagnoses that includes cerebral infarction, dysarthria,
weakness, aphasia, Alzheimer's, foot drop, basal cell carcinoma, and left artificial knee joint. R65 MDS
(Minimum Data Set) dated 7/15/24 shows she is cognitively impaired and dependent on staff for all care
needs.
On 8/27/24 at 12:47 PM, V16 RN (Registered Nurse) and V3 ADON (Assistant Director of Nursing) was
observed providing incontinence care for R65. R65's incomitance brief was overly saturated with urine.
R65's coccyx and perineum were reddened.
On 8/28/24 at 1:59 PM, V19 CNA (Certified Nursing Assistant) assisted R65 with incontinence brief. R65's
coccyx and perineum were still reddened.
On 8/28/24 at 2:08 PM, V6 RN stated R65 had a skin assessment done on 6/12/24 showing she was a high
risk for skin break down. V6 stated a new order was entered for R65 for zinc cream to coccyx every shift on
8/27/24 by V16 RN. No order in place prior to 8/27/24.
2.
R106 was admitted to the facility on [DATE] with diagnoses that includes osteoarthritis, morbid obesity,
polyneuropathy, hypertension, gout, muscle wasting and atrophy and pain. R106's MDS dated [DATE]
shows she cognitively intact and dependent on staff for her care needs.
On 8/27/24 at 1:05 PM V19 CNA (Certified Nursing Assistant) was observed providing care to R106. R106'
s incontinence brief was saturated with urine. V19 stated she started work at 6am but that was her first-time
providing care to R106.
R106 stated she had not been provided incontinence care since 5am. R106 stated staff have come in the
room turned her call light off without providing her care. R106 stated around 11:30 am V3 ADON (Assistant
Director of Nursing) came in her room and told her she would get V19 to provide her care, but no one
came.
On 8/28/24 at 1:48 PM, 106 stated it was very upsetting to be left sitting in a wet undergarment and not
receiving any help from the staff.
On 8/29/24 at 1:51 PM, V2 DON (Director of Nursing) stated if staff are unable to complete their tasks, they
should inform her. V2 stated her expectation is that residents receive incontinence care every two hours
and as needed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 6 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 - Some
The facility policy Perineal Care date August 2008 states the purpose of this procedure is to provide
cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the
resident's skin condition.
3. On 08/28/24 at 10:55 AM R4 was sitting in the dining room watching other residents play a game. R4 had
long chin hairs. R4 said she wanted the chin hairs removed. She said, she does not like when hairs grow.
On 08/28/24 at 1:56 PM V5 (CNA) stated that female residents should not have chin hairs. [NAME] hairs
should be removed on shower days and as needed. V5 said chin hairs on females are a dignity issue.
On 08/29/24 at 9:37 AM V2 (DON) said female residents should not have chin hairs. Facial hair should be
removed whenever the staff does ADL care and notices it. It is a dignity issue for a woman to have chin
hairs, she could be embarrassed. The staff is expected to shave women.
R4's Face Sheet showed R4 had diagnoses of rhabdomyolysis, lack of coordination, need for assistance
with personal care, atrial fibrillation, rheumatoid arthritis, major depressive disorder, polymyalgia
rheumatica, and osteoarthritis. R4's MDS dated [DATE] showed R4 had moderate cognitive impairment.
4. On 08/27/24 at 11:00 AM R90 was sitting in the hallway. R90 had a left-hand splint. R90's fingernails to
his left hand were long and curled in a downward position. R90's fingernails to his right hand were long and
curled in a downward position. R90 stated he wanted his fingernails cut. On 08/28/24 at 10:18 AM R90's
fingernails to both hands remained long and curled in a downward position.
On 08/28/24 at 2:01 PM V5 stated residents fingernails should not be long, dirty, and curled downward. V5
stated residents nails should be cut on their shower days and as needed. V5 stated the resident could
scratch himself and get an infection from long, dirty nails.
On 08/29/24 at 9:37 AM V2 said residents nails should not be long and curled in a downward position. Nail
care should be performed weekly. Residents with long nails can create skin tears or scratch themselves.
The staff is expected to provide nail care when they provide ADL care.
R90's Face Sheet showed R90 had diagnoses of sequelae of cerebral infarction, acute respiratory failure
with hypoxia, chronic obstructive pulmonary disease, dysphagia, metabolic encephalopathy, seizures,
chronic pain, and spinal stenosis. R90's MDS dated [DATE] showed R90 had severe cognitive impairment.
The same MDS showed R90 was dependent upon staff for personal hygiene. R90's ADL deficit care plan
showed an intervention to provide care with dignity and respect.
The facility's Nail Care Guideline effective 02/2023 Guideline showed: 1. Nail care includes routine cleaning
and regular trimming. 2. Trimmed and smooth nails prevent the resident from accidentally scratching and
injuring his or her skin. The facility's Activities of Daily Living (ADL) policy effective 02/2023 Guideline
showed: 1. In accordance with the comprehensive assessment, together with respect for individual resident
needs and choices, our facility provides care and services for the following activities: A. Hygiene: bathing,
dressing, grooming and oral care. B. Elimination: toileting. Our collaborative professional team, together
with the resident and/or resident representative: 1. Will recognize and evaluate an inability to perform ADL's
or risk for decline in any ability to perform ADL's. 2. Develop and implement interventions in accordance
with the resident's evaluated need,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 7 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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
goals for care, and preferences and will address the identified limitation in an ability to perform ADL's.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 8 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 follow the physician's order to provide wound
care.
Residents Affected - Few
This applies to 1 of 3 residents (R1) reviewed for wound treatment and care in a sample of 37.
The Findings include:
R1 is an [AGE] year-old female with mild cognitive impairment as per the minimum data set (MDS) dated
[DATE].
On 8/29/24 at 10:01 AM, V16 (Wound Care Nurse) and V3 (Assistant Director of Nursing) provided wound
care to R1. V16 removed the old dressing from the right hip wound and observed no hydrofera blue (thick
blue pad to absorb exudate/drainage from the wound). V16 then cleansed the right hip wound with saline,
pat dry it, and applied Hydrofera blue with a gauze dressing.
On 8/29/24 at 10:10 AM, V16 removed the old dressing from the right hip superior wound and observed no
hydrofera blue (thick blue pad to absorb exudate/drainage from the wound).
On 8/29/24 at 10:10 AM, in response to the surveyor's inquiry, V16 stated that she changed R1's wound
dressing yesterday and didn't have an explanation for why hydrofera blue wasn't used yesterday.
On 8/29/24 at 10:15 AM, V16 cleansed right hip superior wound with saline, pat dried, and applied
Hydrofera blue with gauze dressing.
A record review of the R1's Physician Order Sheet indicates cleansing the right hip and right hip superior
wound with saline, applying hydrofera blue, and covering it with a dry dressing.
On 8/29/24 at 11:15 AM, V16 stated, V2 (Director of Nursing) talked to V15 (wound care physician/MD) and
on 8/27/24, during wound rounds, we discussed changing dressing from hydrofera blue to Santyl, and that's
why Hydrofera blue was not used yesterday. I will go and change the Hyfrafera blue dressing to the Santyl
dressing.
On 8/29/24 at 11:27 AM, V15 (Wound Care Physician) stated, We discussed the wound dressing on
Tuesday (8/27/24), and the most updated order is Calcium Alginate with form dressing. The resident has
been on Hydrofera Blue for a while. The staff should have updated the system to reflect my new order and
should have followed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 9 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to provide restorative care services.
Residents Affected - Few
This applies to 2 of 2 residents (R65 and R74) reviewed for rehab services in a sample of 37.
Findings include:
1. R65 admitted to the facility on [DATE] with diagnoses that includes cerebral infarction, dysarthria,
weakness, aphasia, Alzheimer's, foot drop, basal cell carcinoma, and left artificial knee joint. R65 MDS
(Minimum Data Set) dated 7/15/24 shows she is cognitively impaired and dependent on staff for all care
needs.
R65 current care plan includes nursing rehab PROM (Passive Range of Motion) to right hand with 3 sets 4
reps 6-7 days a week as tolerated. Restorative program to apply right wrist splint apply upon rising remove
at night.
Review of R65's restorative care documentation for August 2024 shows she received PROM 18 times
August 1st through August 29th. R65's right hand splint was placed 17 times August 1st through August
29th.
On 8/27/24 at 12:44 PM, R65 did not have a splint on her hand.
On 8/28/24 at 1:39PM, R65 did not have a splint on her hand.
2. R74 admitted to the facility on [DATE]. R74 has diagnoses that includes chronic obstructive pulmonary
disease, morbid obesity, fibromyalgia, schizoaffective disorder, bipolar, depression, stiffness of left ankle,
anxiety, seizures, heart failure, lymphedema, gout, polyarthritis, and systemic lupus. R74's MDS shows she
is cognitively intact and dependent on staff for hygiene, dressing and repositioning.
R74's current care plan includes restorative program for AROM (Active Range of Motion) to bilateral upper
and lower extremities 8 to 10 reps 2 sets twice daily 6-7 days a week. Bed mobility requires assistance with
bed mobility. Resident will turn from side to side in bed 3 set of 3 reps and move up and down and
reposition 6 -7 days a week as tolerated.
Review of R74's restorative documentation show she received AROM 9 times and side to side turning
exercise 9 times August 1st thru August 29th. In July 2024 R74 received AROM 18 times and side to side
activity 20 times. In June 2024 R74 received AROM 18 times and side to side activity 16 times.
On 8/27/24 at 12:21 PM, R74 stated she is supposed to get up a couple of times per week but has not
been gotten up.
On 8/27/24 at 2:21 PM, R74 stated she is supposed to receive restorative visits 6 to 7 times per week but
has gone months without seeing them. R74 stated she saw them the prior week after complaining, but has
not seen them since.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 10 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 8/29/24 at 12:14 PM V20 Restorative Director stated NA restorative documentation means the task was
not done.
On 8/29/24 at 12:20 PM, V21 Restorative Aide stated R65 and R74 have never refused restorative
services. V21 stated she receives a daily list of residents that are to be seen. Residents that have an up
coming MDS are seen first followed by residents that receive walking assistance. All other residents
receiving restorative services are seen after that if there is time.
On 8/29/24 at 12:29 PM, V22 Restorative Aide stated R65 and R74 have never refused restorative
services. States residents that have an MDS scheduled are seen 100% first, walers and everyone else in
between. V22 states she always documents. If the activity did not occur, she documents NA. V22 stated
there is an option to document if a resident refuses. V22 stated she informs V20 of any changes in a
resident if they are not able to do the task so that the care plan can be updated.
The facility policy Rehabilitative Nursing Care dated April 2007 states rehabilitative nursing care is provided
to for each resident admitted to the facility. The facility's rehabilitative nursing care program is designed to
assist each resident to achieve and maintain an optimal level of self-care and independence.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 11 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observations, interviews, and record reviews, the facility failed to have proper fall precaution
measures in place for 4 residents (R33, R14, R69 & R52) who are at risk for falls in a sample of 37.
Residents Affected - Some
The findings include:
1. On 08/27/24 at 10:46 AM R33 was observed in her bed with her bed in a high position. R14 said that the
CNA (Certified Nurse's Assistant) had left the bed in that position for the last hour. V3 ADON (Assistant
Director of Nursing) was present at that time.
R33's 8/27/24 care plan showed that she is at risk for falls related to injury, weakness, impaired balance,
decreased mobility and transfers, poor judgment and decreased safety awareness, dementia, and a history
of falls. The interventions showed keep bed in lowest position with brakes locked.
2. 08/28/24 at 03:09 PM R14 was observed in bed with a mat on the left side of her bed but not on the right
side of her bed.
R14's 6/17/24 care plan showed that she is at risk for fall related injury due to a diagnosis of CVA (cerebral
vascular accident) with left hemiparesis, obesity, decreased mobility and transfers. The care plan
interventions showed floor mats to bedside.
3. On 08/29/24 at 11:45 PM R52 was observed in bed with only 1 mat on the floor on the right side of his
bed.
R52's 7/5/24 care plan showed resident has a history of falling related to status post fall diagnosis
Parkinson disease, dementia, poor safety awareness, and weakness. The intervention showed floor mats at
bedside.
4. On 08/27/24 at 11:31 AM R69 was observed in bed with only one mat on the floor on the left side of his
bed. On 08/28/24 at 03:07 PM R69 was observed in bed with only one mat on the floor on the left side of
the bed.
R69's 6/21/24 care plan showed that R69 has a history of falls and remains at risk for falls related to
diagnoses of Alzheimer's, Dementia, CAD (coronary artery disease), COPD (chronic obstructive pulmonary
disease), Chronic contractures, Closed left femoral neck fracture, and right cerebellar. The interventions
showed floor mats.
On 08/28/24 at 02:25 PM V7 (Physical Therapist) said that if the resident is a high fall risk, there should be
a mat on both sides of the bed, and the bed should be in a low position.
On 08/29/24 at 4:06 PM V2 DON (Director of Nursing) said that if the resident is a high risk for falls, her
expectations are that residents' beds are kept in low positions and that they have mats on the floor on both
sides of the bed.
The facility's Falls and Fall Risk, Managing policy (August 2008) showed, based on previous evaluations
and current data, the staff will identify interventions related to the resident's specific
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 12 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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
risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
Staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as
applicable) to try to minimize serious consequences of
Falling.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 13 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation. Interview and record review the facility failed to maintain the kitchen in a manner that
would prevent foodborne illness.
Residents Affected - Many
This applies to 112 residents that receive their meal from dietary services.
Findings include:
On 8/29/24 at 4:43 PM, 112 residents served from the kitchen on 8/27/24 was confirmed with V2 DON
(Director of Nursing).
On 8/27/24 at 10:03 AM, the kitchen tour was conducted with V25 Dietary Consultant.
The dry storage floors were sticky.
Vanilla wafers 16 oz (ounce) bag was opened and did not have an open on date or use by date.
Spaghetti 10 lb. (pounds) was opened.
Walk in coolerBag of carrots, celery and onion mix opened no label identifying contents, opened on date use by date
8/23/24.
Five-gallon bucket of pickles with unsecured lid
Seven cartons of strawberry topping dated 7/17/24.
Two 24 oz jars of marinara, one half empty, one with the safety seal broken and no opened on or use by
date.
Two metal trays of ham chunks covered with saran wrap stored over three pans of Jello, two pans of
uncooked roll and three pans of uncooked biscuits.
Deli sandwiches one bologna, one turkey and one roast beef dated 8/23/24.
V25 stated he has worked in the facility for two weeks. V25 stated he would not serve the strawberry
topping because he did not know if it was expired. V25 stated he would not serve the deli sandwiches
because they should not be kept longer than 48 to 72 hours. V25 stated there were no logs for the
sanitization buckets.
Walk in freezerTwo fast food restaurant cups with frozen brown liquids and a 16 oz ½ empty bottle of water.
One sanitization bucket in use measured at 100 ppm (parts per million).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 14 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 0812
On 8/28/24 at 11:40 AM, V25 was in the kitchen with facial hair not covered with hair net.
Level of Harm - Minimal harm
or potential for actual harm
On 8/29/24 at 12:46 PM, two large clear bags in the facilities walk in cooler were identified by V18, Dietary
Manager, as shredded chicken did not have a label identifying contents or expiration date. Water was
observed dripping from the ceiling and the kitchen floor was wet.
Residents Affected - Many
On 8/28/24 at 12:16 PM, V25, Dietary Consultant, stated facial hair should be covered. V25 stated the
sanitization buckets are changed every two hours and as needed. The sanitization ppm should be
documented every shift / meal.
Review of the facility provided documentation showed the facility did not conduct consistent daily
monitoring of chemical sanitization level in the or three compartment sinks from December 2023 thru
August 2024. The facility did not provide any documentation for the monitor of their red sanitization buckets.
The facility provided logs for food cooking and holding temperatures from June thru August that show
temperature monitoring is not consistently done with every meal every day.
The facility policy Sanitization and Infection Control dated June 2023 states sanitizer solution should read at
200ppm.
The facility policy Dishwashing and Sanitization dated June 2023 states adequate food temperature will be
maintained throughout meal service and delivery.
The facility policy Food Storage date June 2023 stated food storage areas shall be clean at all times. Left
over foods are labeled, dated, immediately placed under refrigeration and used within 72 hours or
discarded. All exposed foods should be stored tightly covered. No personal items will be stored with food
items.
The facility policy Personnel Health and Sanitization dated June 2023 states employees who handles food
and food contact surfaces use hairnets, caps or other effective hair restraints in order to keep hair from
contacting food and food contact surfaces.
The facility policy Food Temperatures dated June 2023 states hot food temperatures will be taken upon
cooking, holding and on the line before service at each meal. Temperatures will be recorded each time in a
temperature logbook.
The undated facility provided chart for refrigerator storage states always store ready to eat foods on the top
shelf. Arrange other shelves by cooking temperature with the highest cooking temperature on the bottom.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 15 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 0813
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
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 label, date, and discard old food and
beverages from resident's personal refrigerators.
Residents Affected - Few
This applies to 2 of 2 residents (R34 and R49) in the sample of 37.
The findings include:
1. On 08/27/24 at 10:52 AM R34's personal refrigerator in her room had nine soft, and old individual ice
cream sandwiches in the freezer. The ice cream sandwiches did not have an opened or expiration date.
R34 said it's been a long time since I ate one. R34 stated the staff assists her with cleaning out the
refrigerator. On 08/28/24 at 1:43 PM the individual ice cream sandwiches remained in the freezer.
On 08/28/24 at 1:46 PM V13 (Housekeeper) stated she cleans the resident's refrigerators out. V13 said she
did not know R34 had old ice cream sandwiches. V13 said old, soft ice cream should not be in the
refrigerator. R34 could get sick if she eats it.
On 08/29/24 at 9:37 AM V2 (Director of Nursing) said all residents food in the personal refrigerators should
labeled and dated. V2 said the ice cream sandwiches should have been dated and labeled. Residents can
get sick if they eat old food.
R34's Face Sheet showed multiple diagnoses which included heart failure, dementia, muscle wasting,
abnormalities of gait and mobility, depression, hypertension, and ischemic cardiomyopathy. R34's MDS
(MDS/Minimum Data Set) dated 06/05/24 showed R34 was cognitively intact.
2. On 08/27/24 at 11:38 AM R49's personal refrigerator in her room had three cups with an unknown liquid
in them. The cups were not dated or labeled. R49 said she consumes the drinks that are in the refrigerator.
On 08/28/24 at 1:51 PM the cups with unknown liquids remained in the refrigerator, without a date or label.
On 08/28/24 at 1:52 PM V13 said all liquids and cups should be labeled and dated. V13 said residents can
get sick if they drink old beverages.
On 08/29/24 at 9:37 AM V2 said all drinks that are opened should be labeled and dated. Residents can get
sick if they eat old food or drink an unknown beverage.
On 08/29/24 at 2:02 PM V1 (Administrator) said our housekeeping staff is responsible for cleaning all
resident's personal refrigerators. We clean them out, discard old food and drinks whether the resident can
clean it or not. I'm not sure how often they are cleaned. If a resident consumes old food and beverages, the
residents could potentially become sick. There could also be an odor in the room from old foods.
R49's Face Sheet showed multiple diagnoses which included fracture of left pubis, osteoporosis, chronic
kidney disease, atherosclerotic heart disease, major depressive disorder, dysarthria, dementia, and anxiety
disorder. R49's MDS dated [DATE] showed R49 had severe cognitive impairment.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 16 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 0813
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
The facility's Use and Storage of Outside Foods in Resident's Room Policy showed: To ensure that food
brought into the facility is stored, handled, and consumed safely, these instructions must be followed. 2. Any
food or beverage must be dated and labeled with the resident's name. 3. Unlabeled food will be discarded.
5. Any perishable food or leftover foods not consumed after 3 days will be discarded. Refrigerator in
resident's room: 4. Facility staff are responsible to ensure the refrigerator is clean at all times. 5. Date and
label all food items.
Event ID:
Facility ID:
145538
If continuation sheet
Page 17 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 follow its Enhance Barrier Precautions (EBP)
Guidelines by staff not wearing gowns during incontinent care to EBP residents and not having a trash can
inside the resident room and near the exit for discarding PPE after removal. The facility also failed to
maintain effective hand hygiene during resident care.
Residents Affected - Some
This applies to 4 of 4 residents (R1, R56, R40, and R80) reviewed for infection control practices in a sample
of 37.
The findings include:
1. R1 is an [AGE] year-old female with mild cognitive impairment as per the Minimum Data Set (MDS)
dated [DATE]. On 8/28/24 at 1:57 PM, V8 (Licensed Practical Nurse / LPN) stated that R1 is on EBP
because of her wounds, suprapubic catheter, and nephrostomy tube.
On 8/28/24 at 10:20 AM, the surveyor observed V9 (Certified Nursing Assistant -CNA) & V10 (CNA)
providing incontinent care to R1 without wearing a gown.
On 08/28/24 at 10:25 AM, V8 stated that anybody with wounds or catheters is treated as EBP. When staff
provide incontinent care to those residents, they are supposed to wear gowns.
2. R56 is a [AGE] year-old female with mild cognitive impairment who has a suprapubic catheter due to
bladder dysfunction. On 08/28/24 at 11:15 AM, her room was observed with an EBP sign, no PPE cart at
the door, and no trash bin at the exit door to discard used PPEs. V8 was observed checking R56's blood
sugar without wearing a gown.
On 8/28/24 at 11:18 AM, observed V8 administering 9 units of Aspart insulin to R56 without wearing gown.
V8 stated that R56 is on EBP due to suprapubic urinary catheter.
On 8/29/24 at 10:37 AM, V6 (Infection Preventionist) stated, As V8 and V9 were giving direct care to R1,
they should have worn gowns. V8 also should have worn a gown when she was checking R56's blood
sugar. There should have been a trash bin at the exit door for R56 to discard used PPEs.
On 8/28/24 at 11:20 AM, no trash bins were available at R56's exit door to discard PPEs ((Personal
Protective Equipment).
The facility presented EBP Guidelines documents:
2. Initiation of Enhanced Barrier Precaution
b. Implement EBP for residents with wounds, urinary catheters, and
feeding tubes
3. Implementation of EBP
c. Position a trash can inside the resident room and near the exit for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 18 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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
discarding PPE removal .
Level of Harm - Minimal harm
or potential for actual harm
5. EBP should be followed . when anticipating close physical contact while
assisting with transfers and mobility or any high-contact activity.
Residents Affected - Some
4. High-contact resident care activities include:
f. Changing briefs or assisting with toileting.
3. On 08/27/24 at 12:21 PM R40 was in her room sitting in her recliner. Her Foley catheter bag was hanging
from her wheelchair in front of her. At 12:27, V2 DON (Director of Nursing) asked V4 CNA (Certified Nurses'
Assistant) to move the bag to R40's bed frame closer to R40. V4, with ungloved hands, moved the catheter
bag that was filled with reddish colored urine, from under R40's wheelchair to the bedframe next to R40.
Then V4 assisted in setting up R40 lunch tray touching the food items on her tray including opening up her
carton of milk. V4 did this with ungloved hands.
On 08/27/24 at 12:30 PM V4 said that she should have cleaned her hands after moving the catheter bag
and before setting up R40's tray including opening the carton of milk. V4 said she should have done this so
she would not contaminate R40's food.
On 8/29/24 at 4:06 PM V2 DON said that the staff should have clean her hands after moving R40's catheter
bag before she setup her lunch including opening R40's carton of milk.
R40's electronic health record showed that R40 has a history of urinary tract infections.
R40's 8/29/24 physician orders showed - Culture, catheter urine, related to history of urinary tract infections
and Urinalysis, related to history of urinary tract infections. R40's MDS (minimum data set) section GG
showed that R40 needs setup assistance for eating.
The facility's Hand -Washing/Hand Hygiene Policy (March 2020) showed, it is the policy of the facility to
assure staff practice recognized hand washing hand hygiene procedures as a primary means to prevent
the spread of infections among residents, personnel, and visitors. When hands are not visibly soiled,
employees may use alcohol based hand rub, foam, gel, liquid containing at least 60% alcohol in all of the
following situations: after direct contact with residents, before performing a non-surgical invasive procedure,
before handling clean or soiled dressing gauze pads etc., after contact with the residents intact skin, after
handling used dressings, potentially contaminated equipment, etc., after contact with objects such as
medical devices or equipment in the immediate vicinity of the resident that may be potentially
contaminated, after contact with potentially infectious materials, during resident meal service, in between
tray pass if contact with resident is made hand hygiene should be used, when removing trays hand hygiene
should be used, & before contact with fresh tray or with a resident.
4. 08/27/24 at 12:40 PM R80 was receiving perineal care from V4 & V5 CNAs (Certified Nurses'
Assistants). R80 was in the bathroom in a standing position with the use of a Sit to Stand lift. V4 was
observed wiping R80's buttocks 7 times without folding or turning the cloth towel. Then with the same cloth
towel V4 washed R80 perineal area at least 9 times without folding or changing the towel.
On 08/27/24 at 01:04 PM V4 (CNA) said that she should have had had another cloth or folded the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 19 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 - Some
washcloth or only wiped one time when she was providing perineal care. V4 said that this should be done to
prevent cross contamination. V4 said that she did it because she was rushing because she did not want
R80 to fall.
On 08/29/24 at 04:06 PM V2 (DON) said that her expectations are that when staff are providing perineal
care they wipe once then fold the washcloth before wiping again.
R80's electronic health record showed diagnoses including hemiplegia and hemiparesis, muscle wasting
and atrophy, altered mental status, attention and concentration deficit following cerebral infarction, lack of
coordination, and weakness.
R80's 7/30/24 MDS (minimum data set) Section GG showed that R80 is dependent on staff for toileting
hygiene.
The facility's Perineal Care policy (revised August 2008) showed the purpose of this procedure are to
provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the
resident's skin condition. For female residents wash peroneal area wiping from front to back, then wash the
rectal area thoroughly wiping from the base of the labia towards and extending over the buttocks do not
reuse the same washcloth or water to clean the labia.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 20 of 21
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
145538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beecher Manor Nrsg & Rehab Ctr
1201 Dixie Highway
Beecher, IL 60401
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 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Potential for
minimal harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide a pest-free environment to residents
by having house flies and gnats in the resident rooms and common areas.
Residents Affected - Many
This applies to all 117 residents residing in the facility.
The Findings include:
R57 is a [AGE] year-old female with moderate cognitive impairment as per the Minimum Data Set (MDS)
dated [DATE].
On 8/27/24 at 11:31 AM, the surveyor observed house flies in R57's room and on R57.
On 8/27/24 at 11:31 AM, R57 stated, I do have flies here, and I don't know how to get rid of them.
08/27/24 02:29 PM, house flies around the food cart were observed in front of the Kitchen hallway.
On 8/28/24 at 10:13 AM, the surveyor observed R57's room again with a house fly on her (left leg).
08/28/24 at 10:32 AM, observed gnats and house flies around North Nurse's station.
On 08/29/24, at 11:20 AM, house flies were observed in the South Nurse's station.
As per the surveyor's notification, V3 (Assistant Director of Nursing/ADON) cleansed the nurse's station and
stated, Those flies are everywhere.
On 8/28/24 at 1:46 PM, V17 (Maintenance Director) stated, We treat our facility with a pest control company
twice per month. We were treated on 8/16/24. I notified them yesterday. They said they will spray chemicals
outside on next visit. I know residents should have a pest-free environment.
A review of the facility-provided pest control policy dated 11/1/23 document:
1. Ongoing measures are being taken to prevent, contain, and eradicate common household pests such as
bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145538
If continuation sheet
Page 21 of 21
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
12 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.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
FAQ · About this visit
Common questions about this visit
What happened during the August 30, 2024 survey of BEECHER MANOR NRSG & REHAB CTR?
This was a inspection survey of BEECHER MANOR NRSG & REHAB CTR on August 30, 2024. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BEECHER MANOR NRSG & REHAB CTR on August 30, 2024?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
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.