F 0839
Employ staff that are licensed, certified, or registered in accordance with state laws.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
Interview and Record Review, the facility failed to hire and maintain a current and active license for a
Registered Nurse (RN) and allowed that RN to work unlicensed upon hire.
Residents Affected - Some
The Findings Include:
On [DATE] at 11:50 AM, While doing the background check review, one of the facility's RNs (V4) was found
to have an expired license and has been working at facility since hired on [DATE].
On [DATE] at 11:52 AM, V1, Administrator, stated I did the background checks on (V4, RN), and I never
noticed that her license was expired. I just called (V4) who told me that she thought she renewed her
license, but she doesn't have a receipt to prove it. (V4) was calling the Illinois Department of Financial and
Professional Regulation (IDFPR) to discuss this with them and will let me know of the outcome.
On [DATE] at 12:35 PM, V6, Business Office Manager, stated There are three of them who do the
background checks for new employees, V1, herself, and V7, Medical Records.
On [DATE] at 12:37 PM, V7 stated We run fingerprints on date of hire or before, but since it takes a while to
get them back, we usually accept the acknowledgment email from state indicating they received it, and that
the employee is eligible to work with nothing flagged so far.
On [DATE] at 12:45 PM, V1 stated I am the one who did (V4's) background check and I printed them out,
and never saw the expiration date on her RN license. (V4) has been taken off the schedule. (V4) called the
state who told her they never received a check to pay for the license renewal, therefore, it was not renewed
and (V4) will have to send a letter indicating what happened and the board will review the issue and get
back with her.
On [DATE] at 1:45 PM, V1 stated The facility is staffed with two Nurses and five CNAs for Days and
Evenings, then one to one and half Nurses and three CNAs for Nights. (V4) only works on Hall-Two with
rooms 14 through 36.
V4 was hired on [DATE] with a IDFPR License check completed upon hire. This License check indicated
that V4's RN License expired on [DATE], prior to V4 being hired by the facility.
The Facility's Nursing Schedules from [DATE], through [DATE], were reviewed with V4, RN, working 35
shifts as an RN on the floor. V4 cared for R2, R3, R4, and R5 during her shifts.
(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:
145921
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
145921
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hitz Memorial Home
201 Belle Street
Alhambra, IL 62001
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 0839
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
R2's, R3's, R4's, and R5's Medication Administration Record (MAR), dated [DATE], documents V4
administered medications to each resident on the shifts that she has worked at the facility.
The Facility's Policy and Procedure Abuse and Neglect, undated, documents Employee Screening and
Training: Before new employees are permitted to work with residents, references provided by the
prospective employee will be verified as well as appropriate board registrations and certifications regarding
the prospective employee's background. Licensed Staff: The facility will not employ or otherwise engage a
licensed professional who has a disciplinary action in effect against his or her professional license by a
state licensure body as a result of a finding of abuse, neglect, and exploitation, mistreatment of residents or
misappropriation of resident property. A criminal background check will be conducted on all prospective
employees as provided by the facility's policy on criminal background checks.
Event ID:
Facility ID:
145921
If continuation sheet
Page 2 of 2
