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 keep resident care areas clean and
in a good state of repair for 5 (R3, R4, R6, R8 - R20) of 16 residents reviewed for homelike environment in
a sample of 20.
Findings Include:
On 09/24/2024 at 9:54 A.M. an observation in the 100-hall shower room revealed the following: shower stall
had a black / orange substance around the caulking strip area between the wall and the floor. The black
substance was observed as being around both side walls and the back wall of the shower stall. The vinyl
liner for the shower curtain was observed as having black speckles on the bottom 12 inches. The vinyl liner
also had an orange / brown substance on the bottom 6 inches of it. The legs of the shower chair had a
orangish / black substance above the wheels.
On 09/24/2024 at 11:32 A.M. V4 (Family member) stated the facilities shower rooms are gross and are filled
with mold. V4 stated she expressed her concern in the last care plan meeting she had with the facility on
08/29/2024. V4 stated she showed V2 (Director of Nursing) and V12 (Social Service) pictures of the shower
room and the shower room curtain liner. V4 stated she was told that it wasn't mold and there had been
nothing done about the shower curtain liner.
On 09/24/2024 at 12:03 P.M. V5 (Housekeeping Supervisor) was observed cleaning the shower stall on the
300-hall shower room. V5 stated she is not sure what the black / orange substance is that is on the
stripping of the shower stall where the wall and floor meet. V5 stated the facility has tried removing it with
different cleaning products including bleach. V5 stated that she has been unsuccessful as she thinks it is
the glue coming through. V5 stated the shower rooms are cleaned at least daily and more often if needed.
V5 stated that the facility is in the process of preparing to remodel all three shower rooms.
On 09/24/2024 at 12:31 P.M. V1 (Administrator) stated she does not think the discoloration in the shower
rooms is mold. V1 stated they have sprayed it with bleach, and it does not change the color or make it
where it will come off. V1 stated she feels that is the glue from the tiles and stripping causing the black
appearance. V1 stated it is very sticky and won't come off.
On 09/24/2024 at 2:50 P.M. V1 and V9 (Regional Nurse) were shown the shower curtain liner on 100 halls.
V1 stated that she was unaware that there was soap scum build up on the back of the shower curtain liner.
V1 stated they will immediately take them down. V1 stated the buildup on the shower chair legs was not
mold it was soap scum. V1 stated that she has no complaints from residents or families about the condition
of the shower rooms.
(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:
146134
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
146134
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saline Care Nursing & Rehab
120 South Land Street
Harrisburg, IL 62946
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 09/25/2024 at 8:56 A.M. the 100-hall shower room was observed to have a new vinyl liner with the
shower curtain.
On 09/25/2024 at 08:30 A.M. V1 stated that all of the shower chairs are being taken outside and being
power washed. V1 stated that this occurs twice a month for each side. V1 stated that the facility is getting
ready to start a remodel on three of the shower rooms. V1 stated they are waiting for all the materials to be
delivered so the project can get started.
On 09/25/2024 at 9:01 A.M. V2 (Director of Nursing) stated she was in the care plan with V4. V2 stated she
remembers V4 telling them about the shower room but does not remember V4 stating issues with the
shower curtain or liner. V2 stated after the care plan meeting, she looked at the shower and does not
believe it is mold. V2 stated she believes it is glue coming through. V2 stated the facility is getting ready to
start a remodel on all three shower rooms.
On 09/25/2024 at 9:35 A.M. V1 stated that all housekeeping staff have been instructed to monitor the liners
in the shower room and to change them as needed.
Facility Census sheet printed 9/24/24 documented R3, R4, R6, R8 - R20 live on the 100 hall.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146134
If continuation sheet
Page 2 of 2
