Inspection·December 5, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review, the facility failed to maintain the shower room on the South Hall in a clean and sanitary condition. This has the potential to affect 23 residents residing on the South Hall. Findings include: On 12/02/24 at 10:19am, the shower room B on the South hall was observed to have an area in the corner behind the toilet where there was a significant buildup of an unknown black substance. On 12/02/24 at 10:32am, R2 who was alert to person, place, and time, stated that the shower rooms could be cleaner at times. On 12/02/24 at 10:53am, R13 who was alert to person, place, and time, stated the facility was pretty dingy before they started painting around here and the bathrooms are often dirty and damp. On 12/02/24 at 11:02am, R11 who was alert to person and place, stated the bathrooms could use a good cleaning. On 12/02/24 at 11:43am, V3 (Housekeeping) took a rag that was damp with cleaner and attempted to wipe an area of black buildup in the corner by the toilet of shower room B on the South hall, it did not wipe off after multiple swipes. It appeared that some of it was under a layer of clear sealant. On 12/04/24 at 10:00am, The buildup in the corner of shower room B was clean, there was no longer any clear sealant observed on the wall. On 12/04/24 at 12:00pm, V8 (Certified Nursing Assistant/CNA) stated everyone on this end of the South hallway uses shower room B. V8 stated it has a toilet and a shower and there is no one bed bound on the hallway, so it is possible that they all could use it at one time or another. On 12/04/24 at 12:00pm, V8 (CNA) confirmed that there were 23 residents on this end of the South hallway. On 12/04/24 at 1:40pm, V1 (Administrator) was asked about the spot in the corner of shower room B, she stated she did not know anything about it but assumed that housekeeping would have cleaned it. A review of the facility floor plan and census dated 12/03/24, documents there are 23 residents that reside in zone 3 of the south hallway where shower room B is located. (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: 146121 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 146121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benton Rehabilitation and Health Care Center 1409 North Main Street Benton, IL 62812 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)