Inspection·July 27, 2023

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 (showers) for four (R6, R18, R30 and R36) of 16 Residents reviewed for hygiene in a sample of 22. Residents Affected - Some Findings include: Facility Shower Care Policy and Procedure, revised 11/24/20, documents that it is the practice of this Facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. Facility Shower Schedule, effective 3/1/2012, documents that all Residents residing in the Facility are scheduled to receive a shower twice a week. Facility Certified Nursing Assistant Job Description, documents: this position is to assist the nurses in the providing of Resident care primarily in the area of daily living routine; must be physically and mentally capable of performing routine, repetitive job duties; knowledge of State and Federal Regulations; carry out assignments for resident care including bathing and grooming; and be responsible for the well-being and nursing care of all residents assigned to his/her unit while on duty. Facility Resident Council Minutes, dated 1/10/23, document: showers (100 Hall) still not being done, they are told by staff that they are short of help; feel nurses spend too much time at nurse's desk; showers (400 Hall) said their showers are better they at least get one shower a week. Facility Resident Council Minutes, dated 5/9/23, document issues with showers on Second Shift, Residents are told they are too short on staff to do them. Facility Resident Council Minutes, dated 6/13/23, document issues with showers on second shift are not being done on regular basis and that V2 (Director of Nursing) has talked to staff and shower audits are also in place and being tracked. Facility Resident Council Minutes, dated 7/11/23, document that showers again have not been done in a timely fashion and that Residents feel that more staff is needed. R30's Minimum Data Set/MDS, Section G, dated 5/21/23, documents that R30 requires staff assistance with bathing. R30's current Care Plan documents, requires extensive assistance of one to two staff to provide showers (two times a week) and as necessary. (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 5 Event ID: 145604 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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)