F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on interview, observation and record review, the facility failed to ensure call lights were responded to
in a timely manner for 8 of 8 residents (R1, R2, R3, R8, R9, R10, R12 and R13) reviewed for improper
nursing care in the sample of 13.
Findings include:
The facility's Call light Policy (revised 03/27/19) documents the following: All staff responds promptly when
the call system is activated.
On 01/16/25 at 02:30 PM, R1 stated, Sometimes you just have to wait a few moments because they may
be helping someone else. They come as soon as they can, but it can be 30 minutes on some days.
On 01/16/25 at 02:50 PM, R2 was lying in bed watching television. R2 stated there is ample staff in the
building most of the time and added that staff can appear overworked and stressed on days when they
seem to have less scheduled, I think it's harder on them if someone can't come to work because they are
sick, and it can take longer for staff to respond to call lights on those days. Sometimes if they are busy with
someone else, you have to wait your turn. I've waited as long as 30 minutes, or someone has come within 5
minutes.
On 01/16/25 at 03:10 PM, R3 was sitting upright in bed watching television with the head of her bed
elevated approximately 60 degrees. R3 stated, There has been a big change here. This place was sold a
little over a month ago. All of the staff are very nice to me. I have never met such a kind group of people.
Sometimes you have to be patient when they are busy. They all work very hard and have a lot of people
that rely on them for help. It seems like there used to be another person working. It has taken them quite a
bit longer to respond to call lights lately.
On 01/30/25 from 01:00 PM - 01:38 PM, R8 was sitting in her wheelchair with a bedside table positioned in
front of her. R8 stated, I don't want to be here. I have Lyme's Disease and have to re-learn how to walk. I
got it back in 2020 when I was mowing my mom's grass. I had to scrape over 30 ticks off of my ankles and
ended up with a huge bullseye rash on my thigh. Recently, I've just had a bad bout and have went downhill
fast. R8 then stated that staff, Take too long to answer my light and I think it's disgusting. I was on an
antibiotic several weeks ago, and it gave me terrible diarrhea. I had an accident and waited 1 hour and
fifty-five minutes for someone to respond. Believe me- I timed how long it took someone to respond.
Imagine sitting in diarrhea for that long. That is inexcusable. The call light to R8's room was on at 01:00 PM
when this surveyor entered the room, which had been activated by R13 (R8's roommate). An unidentified
staff member responded to R13's call light need at 01:17 PM while R8 was being interviewed.
(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 2
Event ID:
145703
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
145703
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Silvis Center for Nursing Rehab & Care
1455 Hospital Road
Silvis, IL 61282
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 01/30/25 at 01:34 PM, R13 (R8's roommate) stated, They never come when you turn your light on. You
have to wait forever.
On 01/30/25 at 02:25 PM, R9 was sitting up in bed wearing non-slip socks. R9 stated she was very hard of
hearing. R12 (R9's roommate) spoke up with details to add while an interview was conducted with R9. R9
stated she has been at the facility for 8 years, and verified she recently fell at the facility, I was standing in
my room and just went down backwards. (R12) saw me fall and called for help, but no one came. She had
to get out of bed, and yell down the hall for someone. R12 then pointed to her nearby call light and added, I
hit my light after (R9) fell. I had to get out of bed and yell for help because it takes them so long to come
answer your light. It is usually at least 20 minutes before someone comes.
On 01/30/25 at 02:40 PM, R10 stated, The service here is terrible. You have to wait forever for someone to
come if you need help. If you push your call light you might as well forget it because they do not come. I
have waited well over an hour for someone to come.
On 01/15/25 at 02:05 PM, V9 (Licensed Practical Nurse) stated the facility has recently cut the staffing
numbers following a change in ownership. V9 stated, Staff members are stressed out and overwhelmed at
times and have been having a difficult time getting things done.
On 01/16/25 at 09:30 AM, V14 (Certified Nursing Assistant) stated the facility recently made staffing
changes after the facility changed ownership. V14 stated, They cut the staff hours. It is hard not to fall
behind because I feel like we need more staff. It seems like the residents have had to wait longer, and they
are not getting the care they were used to.
Monthly Resident Council Minutes (dated 11/07/24) document the following: Nursing: Residents at council
said their call lights are not being answered in a timely order.
On 02/03/25 at 09:40 AM, V2 (Director of Nursing) stated all staff are responsible for responding to a
resident's call light and call lights should be answered in a timely manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145703
If continuation sheet
Page 2 of 2
