Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R3's
Facility Reported Investigation (FRI) dated 11/7/21 documents, Initial Report on incident documents, During
breakfast, (R3) was observed spilling hot tea on right side. She was taken to her room and assessed. There
was some redness to right abdomen and thigh. A cool compress was applied at that time and she denied
any pain. Her POA (power of attorney) and MD (medical doctor) were notified. Later, the evening nurse
noted a broken blister on right abdomen and one on right thigh. Silvadene was applied at that time and
nurses to monitor the areas daily and as needed. Both areas are healing well at this time.
R3's Final report, not dated, documents, Final report, An investigation was started immediately.
Investigation was completed and all kitchen staff were in-serviced on the Serving Hot Beverages and Soup
policy in place. They each expressed understanding of the policy and a copy has been hung up in the
kitchen, So they have easy access to it, if they have any questions. The IDT (interdisciplinary team) met
and agreed that all new hires will be in-serviced on this policy on their initial orientation and the dietary
manager and Administrator will do periodic audits to make sure staff are in compliance with this policy.
Nursing continues to apply silvadine and a dressing to the areas, until completely healed. See attached
policy and in-service.
R3's Physician Order Sheet dated 11/14/2021 documents, Change right lower quadrant (RLQ) and Right
upper leg dressing daily. Cleanse burn wound apply silvadene, and nonadherent dressing, one time a day
for burn.
On 11/17/21 at 2:50 PM, V13, Dietary worker, stated, I did not check the temp of the tea the day (R3)
spilled tea and was burned. The tea is brewed in the coffee machines.
On 11/18/21 at 11:05 AM, V2, Director of Nurses (DON), stated, I would expect dietary staff to check the
temperatures of food and drinks before serving to the residents.
The facility Policy and Procedure for Serving Hot Beverages and Soup dated July 2007 documents , Policy:
The Food Service Department will monitor the temperature of all hot liquids being prepared to ensure that
hot liquids are served at a temperature that will prevent burns if they should come into contact with skin.
Procedure: 1. The Food Service Manager will monitor temperature that coffee is brewed at. 2. Drip coffee
machines need to be at least 180 degrees F to brew coffee. However, many coffee machines are turned up
to 195 degrees F or greater. Please test the temperature at which the coffee is being brewed and contact
the coffee machine owners for instructions on how to turn the temperature down to 180 F. 3. The coffee
should be chilled to 120-130 degrees (118-124 degrees was hand-written on the policy) before being
served to residents. 4. The Food Service Department is responsible for ensuring that all hot beverages
leave the kitchen at the proper temperature. This includes hot
(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 6
Event ID:
146051
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
146051
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Barry Healthcare & Sr Living
1313 Pratt Street
Barry, IL 62312
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
beverages for activities.
Level of Harm - Actual harm
3. R26's health status note dated 9/15/2021 at 02:19pm documents that R26 had a fall at 1:30 AM. R26's
note documents R26 appears to have hurt right shoulder or arm, it was protruding at an awkward angle.
Sent to the hospital.
Residents Affected - Few
R26's health status note dated 9 /15/2021 at 08:42 pm documents that R26 returned from hospital ER
(Emergency Room) at this time by ambulance. Sling in place on RUE (right upper extremity) d/t (due to)
humerus (upper arm bone) fracture. R26's note documents that R26 denies pain upon arrival. R26's note
does document that R26 did return to the facility with orders for pain medication.
The facility long term care initial report to the Department dated 9/15/2021 documents alert resident found
lying on the floor in room next to bed and stated fell and hurt arm. R26 assessed and complaining of right
shoulder pain. Report documents area assessed and noted abnormal positioning of upper arm/shoulder.
Form documents returned to the facility with sling to right arm and diagnosis of proximal right humerus
fracture.
The facility serious injury final report to the Department dated 9/23/2021 documents that R26 was found
unresponsive and sent back to the hospital on 9/16/2021 and admitted for severe anemia. The report
documents upon admission R26 was found to have a displaced right femur (thigh bone) fracture.
On 11/18/21 08:20 AM, V1, Administrator, stated when R26 had initial fall was sent to local hospital and
diagnosed with fractured proximal humerus which V1 stated documented on initial report. V1 stated R26
had an unresponsive episode, was sent to a different hospital, and was found with a non-displaced fracture
of right femur. V1 stated they assume it was from the first fall. V1 stated the facility has no investigation
when femur fracture identified nor was public health notified when fracture identified but sent in final report
of humerus fracture.
R26's CT (computerized tomography) scan report dated 9/17/2021 documents comminuted fracture of the
right greater trochanter with mild to moderate displacement of the greater trochanter. and small
intramuscular hematoma in the lateral right gluteus muscle. R26's hospital discharge notes dated 9/22/2021
documents weight-bearing as tolerated to RLE (right lower extremity).
The facility Fall Policy dated, revised documents following any falls, the facility staff completes and
occurrence Report. Details of the fall will be recorded, and potential causal factors identified and
investigated. Interventions will be implemented, and Care Plan updated.
Based on interview and record review, the facility failed to provide supervision to prevent falls, investigate
falls and to identify causal factors for 2of 7 residents (R20 and R260 and failed to serve drinks at proper
temperatures to prevent burns for 1 of 7 residents (R3) reviewed for accidents in the sample of 49. This
failure resulted in R20 falling, sustaining a second fracture to the right hip, in the same location that was
previously surgically repaired, and requiring hospitalization.
Findings include:
1. R20's Face sheet, dated 11/17/21, documents, an admission on [DATE] for skilled treatment/therapy
following a right hip fracture post surgery.
R20s's Minimum Data Set (MDS), dated [DATE], documented, R20 has no recall to the year, month, day,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146051
If continuation sheet
Page 2 of 6
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
146051
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Barry Healthcare & Sr Living
1313 Pratt Street
Barry, IL 62312
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
unable to repeat words, requires extensive assistance with toileting due to urinary incontinence and
requires stabilization of staff with transfers.
Level of Harm - Actual harm
R20's, Fall Risk Data Collection, dated 5/5/21, documented R20 at risk for falls and oriented to self only.
Residents Affected - Few
R20's Care Plan, initiated date of 5/5/21, documented, I am at risk for falls d/t (due to) a right hip fx.
(fracture) and poor safety awareness. Fall Interventions put in place on 5/5/21: 1. Care givers are to make
sure that all of my wants and needs are met before leaving room. 2. Low bed, mat placed at bedside. 3.
Make sure the bed is always locked, also a fall star located outside of residents entry door.
The facility's Fall Incident Report, documented R20's fall history that occurred on; 5/5/21, 5/7/21, 6/19/21,
6/28/21, 7/2/21 and 7/21/21.
R20's Fall Incident Report, dated 5/5/21, documented, R20 found on the floor in room, lying on stomach,
with no injuries noted.
R20's Fall Incident Report, dated 5/7/21, documented, R20 ws found on the floor, in room, in front of a
wardrobe. Right hip rotated, R20 states that right hip hurts and hit head on the wardrobe table. R20 was
transferred to a local emergency department for medical evaluation. No injuries reported.
R20's Progress Note, dated 5/8/21 at 11:22AM, documented, R20 is alert but forgetful.
R20's Progress Note, (Daily Skilled Nurse Note), dated 5/28/21 at 8:55PM, documented, R20 is confused,
has short and long term memory problems with decision making impaired.
R20's Progress Note, dated 6/17/21 at 4:52AM, documented, R20 has not been sleeping all night.
R20's Progress Note, dated 6/18/21 at 5:09AM, documented, R20 has been restless throughout the night.
Attempted to transfer self, unable to be redirected at times and has had some confusion.
R20's Fall incident Report, dated 6/19/21, documented R20 was sitting in wheelchair in front of the nurse's
station and at 8:00AM, attempted to stand up from chair, unassisted. Fell, lying on the floor on right side
and with wheelchair on top of R20. This event was unwitnessed.
When (R20) is restless, staff are to be 1 on 1 with resident and make sure staff is in reach when up in
wheelchair. admitted to a local hospital on 6/21/21, sustaining a right hip fracture to the same right hip,
previously surgically repaired prior to admission.
R20's Regional hospital documentation, dated 6/22/21, documented a date of service of 6/19/21, with
present medical history of; Periprosthetic fracture around internal prosthetic right hip joint and R20, who
had sustained a fall at the nursing home and recently had a hemiarthoplasty of the right hip in May. (hip
fracture with surgical hardware and re-fractured around the hip socket surgical hardware, due to fall of
6/19/21).
On 11/17/21 at 3:00PM, V1, Administrator, stated she would have expected staff to be visibly present when
R20 is at the nursing station.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146051
If continuation sheet
Page 3 of 6
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
146051
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Barry Healthcare & Sr Living
1313 Pratt Street
Barry, IL 62312
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
On 11/18/21 at 4:55PM, V21, R20's Physician, stated R20 probably should have been supervised by staff ,
if left unattended, in a wheelchair, at the nursing station.
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
The facility's Fall Policy, dated as reviewed 9/17/19, documented, The facility shall ensure that a Fall
Management Program will be maintained to reduce the incidence of falls and risk of injury to the resident
and promote independence and safety.
Event ID:
Facility ID:
146051
If continuation sheet
Page 4 of 6
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
146051
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Barry Healthcare & Sr Living
1313 Pratt Street
Barry, IL 62312
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
Based on observation, interview and record review, the facility failed to wear required Personal Protective
Equipment (PPE) to prevent the spread of COVID-19 and failed to perform hand hygiene to prevent the
spread of infection. This has the potential to affect all 49 residents residing in the facility.
Residents Affected - Many
Finding include:
1 On 11/15/21 at 12:08 PM, During the dining room observation, none of the staff wore protective eyewear.
V11, Registered Nurse (RN), came into dining room to pass masks out to the residents to wear in the
hallway. V11 was not wearing protective eyewear. V7, Certified Nurse Aide (CNA), V13, Dietary staff, V9,
Licensed Practical Nurse (LPN), V10, CNA, V12, RN, were all in the dining room with no protective
eyewear.
At 12:59 PM, V3, LPN, was feeding a resident, was not wearingvprotective eyewear, and facemask was
below her nose. V7, CNA, was feeding a resident and facemask was below her nose.
2. On 11/17/21 at 10:40 AM, V4, CNA and V8, CNA, were providing toileting for R3. V4 cleansed and rinsed
R3's front perineal area then rectal area. V4 then removed her gloves, put new gloves on, no hand hygiene
done between glove changes. V4 dried the areas, pulled up resdient's brief and pants. V4 removed gloves
and put new gloves on, with no hand hygiene between glove changes.
3. On 11/17/21 at 1:30 PM, V14, LPN, brought the treatment cart into R3's room. V14 put gloves on without
performing hand hygiene. V14 removed R3's dressings to abdomen and right upper leg, The dressings all
had a small amount yellowish drainage on them. V14 removed gloves and put new gloves on, no hand
hygiene between glove changes. V14 cleansed the 2 wounds to right abdomen and the wound to right
upper leg with wound cleanser and a 4 x 4 gauze. V14 removed gloves, washed her hands, donned new
gloves and applied Silvadene cream to the wound on her upper abdomen, and leg wounds, then to lower
abdominal wound, non adherent dressings applied to wounds. V14 then removed gloves, no hand hygiene,
with bare hands taped the non adherent dressings and dated them. V14 then put supplies away in the
treatment cart, put gloves on, transferred R3 back to her wheelchair and washed her hands.
On 11/18/21 at 10:16 AM, V12, RN, stated, I would expect hand hygiene between glove changes.
On 11/18/21 at 10:16 AM, V12 stated, she would expect masks to cover both nose and mouth.
The Centers for Disease Control and Prevention Interim Infection Prevention and Control
Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic:
Summary of Recent Changes, 1. Recommended routine infection prevention and control (IPC) practices
during the COVID-19 pandemic: Implement Universal Use of Personal Protective Equipment. If
SARS-CoV-2 Infection is not suspected in a patient presenting for care (based on symptom and exposure
history), HCP working in facilities located in counties with substantial or high transmission should also use
PPE as described below: Eye protection (i.e , goggles or a face shield that covers the front and sides of the
face) should be worn during all patient care encounters.
The facility Policy and Procedure for Infection Prevention and Control Manual dated 2019, documents,
Standard Precautions Hand Hygiene, Appropriate hand hygiene is essential in preventing transmission of
infectious agents. Purpose: To cleanse hands to prevent the spread of potentially deadly
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146051
If continuation sheet
Page 5 of 6
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
146051
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Barry Healthcare & Sr Living
1313 Pratt Street
Barry, IL 62312
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 - Many
infections. To provide a clean and healthy environment for residents, staff and visitors. To reduce the risk to
the healthcare provider of colonization or infections acquired from a resident. Gloves or the use of baby
wipes are not a substitute for hand hygiene.
On 11/15/2021 at 8:20AM, entrance to facility, staff are observed to be wearing surgical masks and no eye
protection. The COVID-19 data tracker documents the community transmission rate for Pike county, where
the facility is located, is high.
On 11/16/2021 at 2:10PM, V20, Regional Director, stated the facility is not wearing face shields/goggles as
the county positivity rate identifies Pike county in the green.
On 11/16/2021 at 3:00PM, V1, Administrator, stated she was providing training on face shields/goggles.
4. On 11/17/21 at 08:35 AM, R26 was in bed. V6, housekeeper, came out of R26's room with mask, shield,
and gloves on. V6 was not wearing a gown. V6 doffed her gloves, did not sanitize her hands or don new set
of gloves and entered R26's room with cleaning spray. V6 exited R26's room, took box of gloves in room
without sanitizing hands or donning gloves and entering room. V6 exited R26's room, got a mop and
entered R26's room. A sign posted on wall outside R26's room documents contact precautions, wash
hands, gown, mask and gloves.
On 11/17/21 at 01:11 PM, V15, LPN, donned gloves at medication cart at the nurse's station. V15 did not
sanitize her hands prior to donning gloves. V15 picked up treatment supplies and proceded down hall with
supplies in hand. V15 donned isolation gown, and changed gloves, but did not sanitize hands between
glove change. V15 removed the dressing from R26's heel, cleansed with wound cleanser, and applied
ointment and dressing. V15 exited the room, doffed gloves, and sanitized hands.
The Resident Census and Conditions of Residents, CMS 672, dated 11/15/2021, documents a census of
49.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146051
If continuation sheet
Page 6 of 6
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
2 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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the November 18, 2021 survey of BARRY HEALTHCARE & SR LIVING?
This was a inspection survey of BARRY HEALTHCARE & SR LIVING on November 18, 2021. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BARRY HEALTHCARE & SR LIVING on November 18, 2021?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
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.