F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on interview and record review the facility failed to answer call lights in a timely manner. This failure
has the potential to affect all 76 residents who reside in the facility. The Facility's Call Lights: Accessibility
and Timely Response policy dated August 2025 documents the purpose of this policy is to assure the
facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow
residents to call for assistance. Call lights will directly relay to a staff member or centralized location to
ensure an appropriate response. All staff members who see or hear an activated call light are responsible
for responding. If the staff member cannot provide what the resident desires, the appropriate personnel
should be notified. The Facility's Grievance Log documents that on 8/6/25 R2 complained about long call
lights. The conclusion of the grievance was Leader Rounding/re-education. On 12/9/25 at 11:00 AM R2
stated The call lights have not gotten any better, if anything they are getting worse. They (staff) tell me they
will be back and they don't come back. I routinely wait an hour to have my call light answered. The Facility's
Grievance Log documents that on 11/19/2025 R11 complained that a CNA (Certified Nurse Aide) turned off
her call light and left without helping her. The conclusion of the grievance was CNA counseled. On 12/9/25
at 11:30 AM R11 stated Getting your call light answered around here is ridiculous. I usually wait at least an
hour after I have turned it on, and if they do come they turn it off and say they are coming back and don't
come back.On 12/9/25 at 12:10 PM R3 stated Call lights are never answered very quickly. Since (the state
agency representative) got here on Friday we are getting our call lights answered very quickly. Managers
are answering call lights and they never do that. They (management) knows your watching the call lights so
they have posted extra people to answer them. It would be wonderful if our call lights were answered like
this all the time. On 12/9/25 at 12:15 PM R9 stated Call lights stay on for at least an hour if not more every
time. On 12/9/25 at 9:30 AM R10 stated I have a lot of trouble getting them (staff) to answer my call light.
I've timed it before at one hour 30 minutes. Sometimes they (staff) come in and say they are coming right
back in and then they don't. I don't think they should turn it off if they aren't going to help us. On 12/5/25 at
2:00 PM V3 (Ombudsman) stated we have a lot of resident complaints coming from (the facility). The call
lights have been an ongoing issue, I have witnessed it myself. I was there visiting someone and their call
light was on for over an hour and when I went to the desk they said they were going to send someone and
never did. I had to go back up to the desk and ask for help and stand and wait for someone to come with
me. On 12/5/25 at 12:00 PM V8 (R5 Family Member) stated that if he turns on her call light it usually takes
about an hour, which is too long. On 12/9/25 at 12:00 PM V9 (R8 Family Member) stated I am here multiple
times a week. Getting anyone to help you is almost impossible. If I turn on her light I know we are waiting at
least an hour if not more. Sometimes I just go find someone but then you have to stay with them until they
come because they will say they are coming but then don't. I was timing her call lights one night, I got very
upset at an hour and a half
(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 4
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
12/09/2025
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 - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
so I had to quit doing that. Friday and today (the call lights) are being answered very quickly. I have seen
people out of their offices that I have never seen out of their offices before.On 12/9/25 at 12:15 PM V10
(Visitor) stated she comes to visit multiple residents who have become friends of hers. V10 stated The call
light situation for all of my friends is awful. Call light times are always at least an hour. But everyone is telling
me that when (state agency representative) is in the facility everyone is helping answer the lights so they
are getting answered much quicker. The Resident Census Report dated 12/5/25 lists 76 residents currently
reside at the facility.
Event ID:
Facility ID:
145703
If continuation sheet
Page 2 of 4
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
12/09/2025
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to serve their posted menu on a consistent basis.
This failure has the potential to affect all 76 residents who reside in the facility.The Facility's Dietary
Manager Job Summary documents it is the the Dietary Manager's responsibility to plan menus with the
dietitian that meet the nutritional needs of residents in accord with recommended dietary allowances and
state and federal regulations. Prepares standard recipes and daily production sheets from each menu cycle
for dietary staff who prepare food-as applicable. Ensures menus are available to all residents and posts in
readily accessible places in facility. The Facility's Dietary Manager Job Summary also documents the
Dietary Manager is responsible to order food economically and efficiently only from sources approved or
considered satisfactory by Federal, state or local authorities. Maintains sufficient inventory of supplies.
establishes effective system to [NAME] inventory and secure storage areas. On 12/5/25 during lunch
multiple residents (R2,R3, R12,R13,R14 and R15) were voicing frustration with their deli meat sandwiches.
Residents overhead saying it was supposed to be a grilled cheese with tomato soup, who eats a regular
sandwich with tomato soup?On 12/9/25 at 10:30 AM R2 stated Since this new company took over they
(kitchen staff) never make what they put on the menu. We find out at the time of the meal that we aren't
getting what we were supposed to because someone ordered wrong or something. That is ok every once in
a while, people make mistakes. This is not someone making a mistake, this is a company trying to save
money. It is awful and no one is listening. Breakfast has no meat ever, if meat is on the menu I guarantee
you it will be switched to eggs the day of the meal. On 12/9/25 at 11:00 AM R3 stated We never know what
we are going to have, it just depends on what they order. And they sure aren't generous with their portions.
This new company are real penny pinchers. On 12/5/25 at 11:15 AM R12 stated the food quality and
quantity has gone down since a new company took over the facility. It's like no one cares about the food
anymore. The food used to be pretty decent. Now we never know what we are getting. Whatever
(V5/Dietary Manager) remembers to order. On 12/5/25 at 11:20 AM R13 stated I have had it with the
kitchen in this place. They never serve what they say they are going to. We have the same things over and
over even when the menu says we should be getting different foods. On 12/5/25 at 11:25 AM R14 stated
The kitchen has gone so downhill. They serve the same basic things over and over again. I don't think i will
ever eat Tilapia again in my life. On 12/5/24 at 11:30 AM R15 stated No one cares about the food. We just
get whatever they have. It has no rhyme or reason. And we usually don't find out the menu has changed
until we get our plate. The Facility's Week 4/ 11-23-25 through 11-29-25 document on Sunday lunch the
dessert was changed from Brownie to Pudding. On the same Sunday Dinner was planned to be Kielbasa
with Pierogies (Dumpling). The Pierogies were changed to noodles.The same week on Tuesday for
breakfast the Waffle was changed to Pancake. Tuesday lunch the Cucumber Salad was changed to tossed
salad. The same week on Wednesday breakfast the Egg Burrito was changed to a Hard Boiled Egg.
Wednesday lunch the Turkey with Herbs was supposed to be served with Parslied [NAME] and that was
changed to [NAME] Pilaf. The Cake/Icing that was planned for dessert was changed to ice cream.
Wednesday Dinner time Broccoli cuts were changed to Squash. The same week on Thursday breakfast the
Cheddar Egg Bake was changed to Scrambled Eggs and the muffin was changed to an English muffin.
Thursday lunch was supposed to be a Chicken Salad sandwich with corn chowder, but it was changed to
Chicken Salad sandwich with corn. Thursday dinner was supposed to be served with Cinnamon Scalloped
Peaches and it was changed to diced peaches.The same week on Friday the Tilapia was to be served with
Scandinavian vegetables and it was changed to mixed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145703
If continuation sheet
Page 3 of 4
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
12/09/2025
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
vegetables. The same week on Saturday the lunch was supposed to be Chicken Tenders with French Fries
and it was changed to Patty of Chicken and Tator Tots. Saturday dinner was supposed to be served with a
dinner roll and was served with a slice of bread instead. The Facility's Week 1/11-30-25 through 12-6-25
documents that on Sunday breakfast the Sausage Patty on the menu was substituted with scrambled eggs.
Sunday lunch was supposed to be served with Tapioca Pudding and was served with Vanilla Pudding
instead. Sunday Dinner was supposed to be a Pork Roast and was changed to Ham. The same week on
Monday lunch the Cucumber Salad was substituted with a Tossed Salad. Monday Dinner was supposed to
be served with Bread sticks and was served with Texas Toast instead. The same week on Tuesday
breakfast the Breakfast Casserole was substituted with Cheesy Eggs.The same week on Wednesday
breakfast the French Toast was substituted with Eggs Your Way. Wednesday lunch was supposed to be a
Hamburger on a Bun with Corn Chowder and Cake/Icing, the substitute was Hamburger on a Bun with corn
and Pudding. The same week on Thursday dinner was supposed to be served with a Brownie and was
served with Pudding. The same week on Friday breakfast the Sausage and Gravy was substituted with
Pancakes. Friday lunch was supposed to be a Grilled Cheese Sandwich with Tomato soup, and it was
substituted with a Deli Meat Sandwich with Tomato soup. Friday supper was supposed to be a Fish
Breaded Filet and was substituted with Tilapia.The same week on Saturday lunch was supposed to be
Chicken Salad sandwich, French Onion Soup, Broccoli Salad, Dinner Roll and Pineapple, it was substituted
with Lasagna Italian Style with peas, Bread Sticks and Chocolate Pudding. Saturday dinner was supposed
to be Lasagna Italian Style with peas, Bread Sticks and Chocolate Pudding, it was substituted with Chicken
Salad sandwich, French Onion soup and soup crackers. The Facility's Week 2/12-7-25 through 12-13-25
documents that Sunday breakfast was supposed to be served Bacon and it was substituted with a Hard
Boiled Egg. Sunday lunch was supposed to be a Ham Steak with Baked Sweet potato and it was
substituted with Turkey and Rice. The same week on Monday lunch was supposed to be a Quesadilla,
Black Beans and Corn, it was substituted with Enchilada Casserole with Lettuce, Tomato and Onion. The
same week on Tuesday breakfast was supposed to be a Hard Cooked Egg, Cereal of Choice and Danish, it
was substituted with scrambled eggs and toast. On 12/9/25 at 1:00 PM V1 (Administrator) acknowledged
that the dietary staff sometimes cannot get the food that is on the menu. V1 stated sometimes it just isn't
available for order so we have to switch it around. V1 stated that she did not feel like this was done
frequently. V1 confirmed that the menus are made 6 months ahead of time. The Facility's Resident Census
Form dated 12/5/25 documents 76 residents currently reside in the facility.
Event ID:
Facility ID:
145703
If continuation sheet
Page 4 of 4