Hammond-henry District Hsp
HAMMOND-HENRY DISTRICT HSP in GENESEO, IL — inspection on October 9, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
abatement plan.On 10/08/25 at 1:48PM a phone conversation was had with the Facility concerning
jeopardy to resident health or plan.On 10/08/25 at 4:22PM the Regional Office requested a revision to the abatement plan.On safety 10/08/25 at 5:04PM the Facility submitted a revised abatement plan.On 10/09/25 at 8:37AM the Regional Office requested a revision to the abatement plan.On 10/09/25 at 9:11AM the Facility
to the abatement plan.On 10/09/25 at 11AM the Facility submitted a revised abatement plan, and the abatement plan was accepted.On 10/09/25 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1.On 10/2/25, V3's employment, with the facility, was terminated.2.10/2/25 at 1150 V2/DON and V15/Risk Manager performed visual assessment of resident (R1) for signs of physical and emotional abuse, no physical marks noted and patient's emotional status unchanged.3.On 10/8/25 V1/Chief Nursing Officer-CNO, V2, and V15 reviewed LTC/Long Term Care Abuse and Neglect Procedures Policy as well as the organization's Behavior Standards.4.V2 reviewed the LTC Abuse and Neglect Procedures Policy and Behavior Standards with the V18/Assistant Director of Nursing-ADON and then all staff on shift on 10/08/25 day shift was educated.5.Staff not working day shift 10/8/25 were called by V18 and V2 and the LTC Abuse and Neglect Policy and Behavior Standards, specific to compassion and empathy, were reviewed.6.Remainder of staff not working or reached by phone on 10/8/25 will be required to receive education on LTC Abuse and Neglect Policy and Behavior Standards, specific to compassion and empathy, prior to working next shift by the V2 or V18 and will be tracked on sign-in sheet.7.Long Term Care Abuse and Neglect Procedures Policy was added by the V2 to contracted staff orientation packet for review prior to first shift, completed on October 8th, 2025.8.On 10/8/25 an Emergency QAPI/Quality Assurance Performance Improvement discussion was held with V1/Chief Nursing Officer, V2, V17/Social Services Director-SSD, V20/ Medical Director and V15 to review the resident audit findings performed and review investigation. On-going audit plan was created.
Five residents a month will be interviewed by Social Services or V2 or designee about cares received and any concerns regarding cares.
These audit findings will be reported monthly on the QAPI scorecard and reported at the quarterly Quality assurance meetings.
145464 10/09/2025
Hammond-Henry District Hsp 600 North College Avenue Geneseo, IL 61254
call, reporting immediately of any concerns related to abuse and where to find the leadership contact
jeopardy to resident health or V18 and will be tracked on sign-in sheet.8. LTC Abuse and Neglect Procedures Policy was added by safety the V2 to contracted staff orientation packet for review prior to first shift, completed on October 8th, 2025.9. 10/8/25 An Emergency QAPI/Quality Assurance and Performance Improvement discussion
audit findings performed and reviewed investigation. On-going audit plan was created, to include monitoring of any concerns/complaints to ensure appropriate follow-up to include reporting of any abuse per policy. five residents a month will be interviewed by Social Services or V2/designee about cares received and any concerns regarding staff.
These audit findings will be reviewed by V17 and the V2 and reported monthly by the V2 on the QAPI scorecard and at the quarterly Quality assurance meeting.10. V15 will monitor all incidents of patient injury and meet monthly with V2 to review for trends for further review.
145464 10/09/2025
Hammond-Henry District Hsp 600 North College Avenue Geneseo, IL 61254
catheter care, and appropriate care to prevent urinary tract infections.
during incontinence care for one resident (R1) of three residents, reviewed for incontinence care, in a
a.m., shows V3/Certified Nursing Assistant-CNA (employment terminated and unavailable for interview) providing incontinence care (with the assistance of V6/CNA) to R1.
Without changing gloves, V3: lowered the bed; pulled down the blankets; pulled out the pillow from underneath R1's buttocks; checked for incontinence; rolled up the reusable incontinence pad from under the resident; rolled R1 to her left side; removed the pillow from between R1's legs; lifted R1's legs and set them on a blue holder; went to R1's closet, reached in, pulled out a clean incontinence brief; walked into R1's bathroom and immediately walked out and went to R1's bed; touched the end of the bed; lowered the head of the bed; placed a clean incontinence brief on R1's bed; walked back to the bathroom; came back out; placed wipes on the bedside table; walked back to the bathroom. walked back to the bedside table with a spray; grabbed the incontinence wipe and threw it on the bed; lifted R1's legs to adjust them; grabbed the wipe and cleaned R1's perineal area; threw the dirty wipe down; grabbed a clean wipe; wiped R1's perineal area; threw the wipe away; grabbed a clean wipe; grabbed paper towels and dried R1's perineal area; adjusted R1's legs and rolled resident over; removed soiled incontinence brief; grabbed a couple clean wipes and wiped R1's buttocks several times; discarded dirty wipe; grabbed a clean wipe; dried R1's buttocks again; discarded dirty wipe; grabbed paper towels and dried R1's buttocks; discarded the paper towels; adjusted the incontinence pad; grabbed the new incontinent brief; tucked the brief under R1; placed the new incontinence brief on R1; removed blue foam pad from under R1's legs and repositions R1; adjusted pillows, blankets, and bed alarm; threw gloves in the trash; pulled out the old trash bag; put a new trash bag in the trash can and then V3 left R1's room. On 10/9/25, at 11:05 a.m., V2/Director of Nursing would not confirm V3 should have changed gloves, from soiled body site to a clean body site, but rather the expectation is to perform hand hygiene for five minutes between dirty to clean surfaces.
Per the Center for Disease Control/CDC, glove changes should occur when: If gloves become soiled with blood or body fluids after a task; If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs; If moving from care on one patient to another patient; and If they look dirty or have blood or body fluids on them after completing a task.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.