Inspection visit
Inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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 have pressure relieving devices in place for
one of one resident (R3) with high risk of pressure injuries in the sample of 12.
Residents Affected - Few
The findings include:
R3's Transfer Discharge report dated April 1, 2024 shows R3 was admitted to the facility on [DATE] with
diagnoses including acquired absence of right foot, pressure injury of left heel, and congestive heart failure.
R3's Care Plan shows R3 has potential for pressure injury development related to peripheral vascular
disease, advanced age, poor safety awareness, and chronic pain. Follow facility policies/protocols for the
prevention/treatment of skin breakdown.
R3's Scale for Predicting Pressure Injury Risk for that R3 has a moderate risk for developing pressure
injuries.
R3's Wound Weekly Observation Tool dated March 20, 2024 shows that R3 had a pressure injury to his
coccyx that healed. R3's Wound Weekly Observation Tool dated April 1, 2024 shows that R3 developed a
stage II pressure injury to his coccyx. R3 Wound Weekly Observation Tool dated March 27, 2024 shows
that R3 has a wound to his left heel. Special equipment/Preventative Measures include air mattress and
foot protectors.
R3's Treatment Medications dated March 1, 2024-March 31, 2024 shows an order for prevalon
boot-continue to wear at all times.
On April 1, 2024 at 9:16 AM, R3 was laying in bed. There was a heel boot noted to his night stand next to
the head of his bed. R3 was laying on his left side with his left foot directly on the bed. At 11:58 AM, V6 and
V10 CNAs (Certified Nursing Assistants) performed peri care to R3. There was an air mattress pump at the
foot of R3's bed that was not buzzing, nor were there any lights on to indicate the air mattress was on. R3's
heel boot was still on the night stand. R3's left foot had a dressing present. There was a small open area
noted to R3's coccyx. At 2:24 PM, V5 LPN (Licensed Practical Nurse) came into R3's room. The air
mattress pump at the foot of R3's bed still had no on indicator lights on. There was a medical grade surge
protector at the head of R3's bed. The plug of the air mattress was halfway out of the outlet. V5 pushed the
plug in and a green light turned on on the pump. V5 said the air mattress was off.
On April 3, 2024 at 10:22 AM, V5 said that R3 should have foot protection on and an air mattress.
(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:
146127
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
146127
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Florence Nursing Home
546 East Grant Highway
Marengo, IL 60152
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 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
V5 said if the air mattress is off, then the mattress will deflate. V5 said the light on the pump is green when
the mattress is turned on.
The facility's Pressure Injury Prevention Guidelines dated June 1, 2023 shows Policy: To prevent the
formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy
of this facility to implement evidence-based interventions for all residents who are assess at risk or who
have a pressure injury present. Interventions will be implemented in accordance with physician order,
including the type of prevention devices to be used and, for tasks, the frequency for performing them.
Prevention devices will be utilized in accordance with manufacturer recommendation (e.g., heel flotation
devices, cushions, mattresses).
Event ID:
Facility ID:
146127
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
146127
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Florence Nursing Home
546 East Grant Highway
Marengo, IL 60152
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to safely perform ADL (Activities of Daily Living) assistance for
one of 12 residents (R21) reviewed for safety in the sample of 12.
The findings include:
R21's Transfer/Discharge Report dated April 3, 2023 shows R21 was admitted to the facility on [DATE] with
diagnoses including acute kidney failure, muscle wasting and atrophy, cognitive communication deficit, fall,
morbid obesity, and dementia.
R21's Care Plan shows R21 requires extensive assistance by two staff to turn and reposition in bed.
R21's Monthly Nursing Screen dated December 19, 2023 shows R21 requires extensive assistance with
two staff members for bed mobility.
R21's Progress Note dated December 23, 2023 at 5:45 AM shows, the nurse was told by CNA (Certified
Nursing Assistant) R21 had a fall and had two skin tears. R21's right elbow and left forearm had a skin tear.
R21 had a large knot on his forehead. 911 was called, the paramedics came. R21's Progress Note dated
December 23, 2023 at 10:15 AM, shows R21 returned to the facility with a head contusion noted to the
right side. R21 was alert to his name and able to verbalize that he fell this morning and hurt his head.
The facility Incident/Accident Report dated December 23, 2023 shows, CNA reported resident had fallen
from the bed during cares. This writer assessed resident and found skin tear to left forearm, right elbow, left
knee abrasion, redness to right forehead. Cat scan head and neck no abnormalities, CNA counseled, staff
in-serviced.
On April 3, 2024 at 9:43 AM, V2 DON (Director of Nursing) said that V7 CNA was performing cares and
getting R21 ready for the morning. V2 said that R21 was rolled onto his side when V7 went to grab
washcloths and R21 rolled out of the bed. V2 said the bed was elevated and there was no floor mats in
place because V7 was performing cares. V2 said that V7 was performing cares on R21 by himself.
Two attempts were made to interview V7 (R21's CNA) and V8 (R21's nurse) on April 3, 2024
unsuccessfully.
The facility's Safe Resident Handling/Transfers policy dated 2023 shows, It is the policy of this facility to
ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide
and promote a safe, secure and comfortable experience for the resident while keeping the employees safe
in accordance with current standards and guidelines. Resident lifting and transferred will be performed
according to the resident's individual plan of care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146127
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
146127
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Florence Nursing Home
546 East Grant Highway
Marengo, IL 60152
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 implement an Enhanced Barrier
Precautions Procedure which applies to all 30 residents in the facility.
Residents Affected - Many
The findings include:
The federal form 671 completed by the facility on 4/1/24 showed the facility census was 30 residents.
On 4/1/24 the facility had no Enhanced Barrier Precautions (EBP) signs up or Personal Protective
Equipment (PPE) carts out for EBP residents.
The facility's EBP list dated 4/1/24 showed R13, R16, and R26 had feeding tubes. R3, R23, R30, and R83
had indwelling urine catheters. R3 also has a daily wound dressing change.
On 4/1/24 at 11:20 AM, V6 and V10 Certified Nursing Assistants (CNAs) provided incontinence care to R16
without wearing PPE gowns during care. No EBP sign was noted on the door at that time.
On 4/1/24 at 11:58 AM, V6 and V10 provided peri care for R3. At that time, V5 Licensed Practical Nurse
entered R3's room to provide wound care. V5, V6, and V10 did not wear gowns while providing cares for
R3. No EBP sign was posted at the time of the cares.
On 4/2/24 at 8:50 AM, V9 Registered Nurse said they had not received any education prior to 4/2/24 in
regards to EBP.
On 4/2/24 at 1:00 PM, V1 Administrator said the facility did not utilize EBP prior to the 4/1/24
implementation date. V1 stated, We do not have a EBP procedure in place at this time. We have a policy
and staff education which will be in place by 4/8/24.
On 4/3/24 at 9:56 AM, V2 Director of Nursing stated, We will be educating staff on EBP procedures for PPE
for residents who should be on EBP. We did not have procedures in place on 4/1/24.
The facility's Enhanced Barrier Precautions Policy revised on 4/1/24 showed residents with indwelling
medical devices should be on EBP. This Policy showed medical devices include: central lines, urinary
catheters, feeding tubes, and tracheotomy/ventilator tubes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146127
If continuation sheet
Page 4 of 4
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Back to topCitations
7 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.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
FAQ · About this visit
Common questions about this visit
What happened during the April 3, 2024 survey of FLORENCE NURSING HOME?
This was a inspection survey of FLORENCE NURSING HOME on April 3, 2024. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FLORENCE NURSING HOME on April 3, 2024?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.