F 0825
Provide or get specialized rehabilitative services as required for a resident.
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 ensure therapy services were provided for two
(R1 and R3) of three residents reviewed for therapy services on the sample list of 3.
Residents Affected - Few
Findings include:
On 3/15/24 from 9:00 AM to 2:00 PM there were no therapists working in the facility, and the therapy room
was locked.
1. On 3/15/24 at 11:05 AM R1 stated, I was in a hospital in Florida after having a stroke, and V3 (R1's
Power of Attorney/POA) wanted me to receive physical therapy closer to V3's house, so that V3 could help
out. The facility told me and V3 the facility would be getting a new physical therapy service provider starting
on 3/4/24 and that I would be able to start therapy, and so far, they have not come to the facility, and I have
not received any physical therapy. I need to get physical therapy so that I can get stronger on my left side
and go back home to Florida.
R1's Social Service Note dated 2/28/24 documents R1 is a [AGE] year-old white female brought today by
medical transport from hospital in (name of city) Florida. R1 is friendly and cooperative and extremely tired
from 12-13-hour ride. R1 appears alert and oriented x 3, was admitted to room XXX. R1 has a diagnosis of
Intracranial Hemorrhage and plans to return home after completing therapy.
V6 (Nurse Practitioner) Note dated 3/6/24 documents R1 is a [AGE] year-old female new admit to facility
from Florida. R1 was living at own home in Florida and wants to return home. R1 had stroke and is in the
facility for Physical and Occupational therapy (PT/OT). R1 states that R1 is weaker on the left side and tires
easily. Came to facility to be closer to V3 (Daughter and Power of Attorney) because V3 wants to help R1.
2. R3's Face Sheet documents R3 was admitted to the facility on [DATE].
R3's Physician Order Sheet (POS) dated 2/21/24 documents Physical/Occupational (PT/OT) therapy, right
hip fracture.
R3's Physician Order Sheet dated 2/22/24 documents discontinue therapy services as of 2/24/24.
R3's Social Service admission assessment dated [DATE] documents R3 was admitted to the facility on
[DATE] with a Closed Fracture of Rip Hip, and reason for admission to receive Physical and Occupational
therapy.
(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:
146104
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
146104
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Haven of Farmer City
404 Brookview Drive
Farmer City, IL 61842
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 0825
Level of Harm - Minimal harm
or potential for actual harm
On 3/15/24 at 1:38 PM, V2 (Director of Nursing/DON) said the facility is currently not providing any therapy
services to residents. V2 said there are two residents in the facility that were prescribed therapy services,
R1 and R3. V2 said on 2/13/24 the facility was sent a letter documenting the termination of the therapy
service agreement, with the final day of service was 2/18/24. V2 said the facility has not provided any
therapy services since 2/18/24.
Residents Affected - Few
Facility assessment dated [DATE] documents Part 3: Facility Resources Needed to Provide Competent
Support and Care for our Resident Population Every Day and During Emergencies. Staff Type: Therapy
Services (Rehab Care: Physical Therapy (PT), Occupational Therapy (OT), Speech/Language Therapy
(SLP), Physical Therapy Assistant (PTA), Certified Occupational Therapy Assistant (COTA).
Letter from (contracted therapy company) dated 2/13/24 documents: Dear Administrator (Contracted
therapy company) is providing a 5-day written notice of termination of Therapy Services with the facility due
to failure to maintain payment terms, pursuant to Section 5.2.2 of the Therapy Services Agreement.
(Contracted therapy company's) final date of service will be Sunday, February 18, 2024.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146104
If continuation sheet
Page 2 of 2
