Country Health
COUNTRY HEALTH in GIFFORD, IL — inspection on May 26, 2026.
Found 5 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
mental or physical condition, can result in physical harm, pain, or mental anguish.
Abuse may be
written, or gestured language that includes disparaging or derogatory terms directed toward a
comprehend, or disability.
145708 05/26/2026
Country Health 2304 C R 3000 N Gifford, IL 61847
authorities.
a staff member to one (R8) resident to the State Agency and failed to report an allegation of resident
in a sample list of nine residents.
Findings include:1. R8's initial report to the State Agency dated 5/24/26 documents on 5/12/26 V26 Certified Nurse Aide (CNA) grabbed R8's wrist ?somewhat forcefully' causing a bruise.
The facility is not able to provide documentation this incident was reported to the State Agency prior to 5/24/26.
The facility daily staffing sheets dated 5/12/26 documents V26 CNA was assigned to R8 to provide cares.
The facility staffing sheets did not show that V26 CNA worked any shift after 5/12/26. On 5/23/26 at 9:22 AM R8 stated V2 Director of Nurses (DON) asked me about my bruise the day after it happened. R8 stated V26 CNA had a ?bear grip' on my wrist. R8 stated she did not think V26 CNA meant to hurt R8 but was ?very rough' with R8. On 5/23/26 at 10:00 AM V2 Director of Nurses (DON) stated unknown staff told him that R8 had a bruise so he did speak with R8 on 5/13/26. V2 DON stated the incident occurred on 5/12/26 when an agency CNA (V26) improperly transferred R8 from her toilet to her wheelchair causing a bruise on R8's Right Forearm. V2 stated he did not report the bruise caused by V26 CNA and should have. V2 DON stated any time a staff member causes a bruise, that incident should be fully investigated and reported to the State Agency. On 5/24/26 at 8:30 AM V1 Administrator stated R8's bruise should have been reported as an allegation of physical abuse. V1 stated the incident should have been initially reported to the State Agency, then V26 CNA should have been removed from resident areas and suspended pending an investigation. V1 stated a full investigation should have been completed and then a Final report to the State Agency should have been completed with the findings. V1 Administrator stated she was not aware of this incident until 5/24/26. 2. R6 and R9's combined initial report to the State Agency dated 5/24/26 documents R6 was verbally aggressive to R9 on 5/17/26.The facility is not able to provide documentation this incident was reported to the State Agency prior to 5/24/26. On 5/24/26 at 12:50 PM V32 Licensed Practical Nurse (LPN) stated she witnessed R6 verbally abuse R9 on 5/17/26 at 7:00 AM but did not report it. V32 LPN stated she did write a nurse progress note about R6's behavior and thought management reviewed the progress notes and would see it. V32 LPN stated she should have reported R6's verbal abuse towards R9 directly to V1 Administrator right when it happened.On 5/24/26 at 2:05 PM V1 Administrator stated V32 LPN should have reported the incident between R6 and R9 on 5/17/26 immediately to V1 Abuse Coordinator or her Designee, V2 Director of Nurses (DON). V1 Administrator stated a resident does not have to use profanity to verbally abuse another resident. V1 stated she would expect staff to make a direct phone call to V1 and/or V2 to report an allegation of abuse instead of only making a progress note. V1 Administrator stated she was not aware of this incident until 5/24/26.The facility policy titled Resident Care Policy and Procedure regarding abuse and neglect, involuntary seclusion, exploitation, misappropriate of resident property, injuries of unknown origin and social media revised January 29, 2026.
All residents have the right to be free of from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. If the incident involves alleged abuse, neglect, or incident of unknown origin, the incident will immediately be reported to the Administrator and the Administrator shall provide the Illinois Department of Public Health with initial notice of the alleged abuse, neglect, or incident of unknown origin via the OHCR Portal or by emailing or telefaxing to the Department a copy of a report of the incident completed immediately after the incident becomes known.
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sample list of nine residents.Findings include:1. R5 and R6's Final Report to the State Agency dated
and facility investigation file does not include any statements from other cognitively intact residents or any staff member with the exception of V8 CNA who witnessed a portion of the incident. On 5/23/26 at 11:40 AM V6 LPN stated she did not witness the incident between R5 and R6. V6 LPN stated V8 CNA was the one who reported this to V6 and as far as V6 knew, V8 CNA was the only person who actually witnessed anything. V6 LPN stated no one ever asked her what happened or asked her to complete a witness statement. V6 LPN stated she thought that was because she did not witness anything. V6 LPN stated she did document this incident in the progress notes so that if anyone had questions, they could refer to the note.On 5/24/26 at 8:35 AM V1 Administrator stated she only interviewed V8 Certified Nurse Aide (CNA). V1 stated she did not interview any residents other than R5 and R6 and/or staff regarding the R5 to R6 incident which occurred on 4/12/26. V1 Administrator stated a full investigation should have been completed due to R5 did have a history of behaviors with staff and other residents. V1 stated V8 CNA reported the R5 to R6 altercation to V6 LPN.On 5/24/26 at 8:55 AM V8 CNA stated she was exiting the public restroom on the South Hall when she saw R5 and R6 hitting each other at the opposite end of the hall. V8 stated she ran towards both R5 and R6 and separated the two residents. V8 stated she then called for V6 LPN who also then came to assist. V8 stated V6 could not have seen anything due to her location on another hall (between the long hall and the pod on south). V8 stated this happened about 12:15-12:30 right after lunch. V8 CNA stated R5 and R6 had already started fighting when they entered the hallway. V8 CNA stated other staff or residents may have seen R5 and/or R6 shortly before that since the residents were finishing their lunch time and there is supposed to be a staff member present for all meals. 2.
R8's Initial report to the State Agency dated 5/24/26 documents V26 Certified Nurse Aide (CNA) ?somewhat forcefully' grabbed R8's wrist on 5/12/26.On 5/23/26 at 9:22 AM R8 stated a staff member (V26) Agency Certified Nurse Aide (CNA) was assisting her from the toilet back to her wheelchair. R8 stated V26 held onto her wrist with a ?bear grip'. R8 stated ?it really hurt' and left a bruise for days. On 5/23/26 at 9:30 AM V1 stated she did not know anything about R8's bruise caused by V26 CNA. On 5/23/26 at 10:00 AM V2 Director of Nurses (DON) stated unknown staff told him that R8 had a bruise, so he did speak with R8 on 5/13/26. V2 DON stated the incident occurred on 5/12/26 when an agency CNA (V26). V2 DON stated he did not speak with V26 CNA, any of the other staff or other cognitively intact residents. V2 DON stated any time a staff member causes a bruise, that incident should be fully investigated and reported to the State AgencyOn 5/24/26 at 8:30 AM V1 Administrator stated R8's bruise should have been reported as an allegation of physical abuse. V1 stated the incident should have been initially reported to the State Agency, then V26 CNA should have been removed from resident areas and suspended pending an investigation. V1 stated a full investigation should have been completed and then a Final report to the State Agency should have been completed with the findings.
The facility policy titled Resident Care Policy and Procedure regarding abuse and neglect, involuntary seclusion, exploitation, misappropriate of resident property, injuries of unknown origin and social media revised January 29, 2026.
After an initial report of suspected abuse or neglect is sent to IDPH, the Administrator or designee shall investigate all alleged incidents of abuse or neglect.
This same policy documents the investigation shall include interviews with all involved parties and potential witnesses. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes.
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prevent accidents.
observation, interview and record review the facility failed to provide a safe transfer for one (R8)
residents.Findings include:R8's Electronic Medical Record (EMR) documents medical diagnoses as Heart Failure, Osteoporosis, Radiculopathy Cervical Region, Repeated Falls, Muscle Weakness, Atrophy, Difficulty in Walking, Anxiety, Unsteady on Feet, Abnormalities of Gait and Mobility, Abnormal Posture and Bone Density disorder. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as moderately cognitively impaired.
This same MDS documents R8 requires moderate assistance with transferring on and off of toilet and is dependent on staff for assistance with toileting personal hygiene, bathing, and dressing.R8's Care Plan intervention dated 3/11/25 instructs staff to utilize gait belt for one assist transfers.
This same care plan documents an intervention dated 7/1/2025 instruct staff to encourage R8 to wear protective sleeves for skin protection.On 5/23/26 at 9:20 AM R8 was sitting in her wheelchair in her room. R8 was not wearing protective sleeves on her arms. On 5/23/26 at 9:22 AM R8 stated a staff member (V26) Agency Certified Nurse Aide (CNA) was assisting her from the toilet back to her wheelchair. R8 stated V26 CNA did not use a gait belt during the transfer. R8 stated all the other girls use one so I don't know why (V26) didn't. R8 stated V26 CNA had a ?bear grip' on her wrist. R8 stated she did not think V26 CNA meant to hurt R8 but was ?very rough' with R8. R8 stated since V26 did not use a gait belt, V26 held onto her wrist with a ?bear grip'.
R8 stated ?it really hurt' and left a bruise for days. On 5/23/26 at 10:00 AM V2 Director of Nurses (DON) stated unknown staff told him that R8 had a bruise so he did speak with R8 on 5/13/26. V2 DON stated the incident occurred on 5/12/26 when an agency CNA (V26) improperly transferred R8 from her toilet to her wheelchair causing a bruise on R8's Right Forearm. V2 stated V26 CNA did not use a gait belt when transferring R8 and did not ensure R8 had her protective sleeves on to help reduce the risk of injury to R8's skin. On 5/24/26 at 9:54 AM attempted to contact V26 Agency CNA with no success.
The facility policy titled Safe Resident Handling Program Policy revised March 18, 2018 documents gait belt usage is mandatory for all resident handling with the exception of mechanical lift use, bed mobility & medical contraindications.
The gait belt will be considered a part of the certified nursing assistant's uniform.
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catheter care, and appropriate care to prevent urinary tract infections.
observation, interview and record review the facility failed to provide timely incontinence care and
residents reviewed for Activities of Daily Living (ADL) in a sample list of nine residents.
Findings include:R2's Electronic Medical Record (EMR) documents medical diagnoses as Unsteady on Feet, Recurrent dislocation of Right Shoulder, Congestive Heart Failure, Dementia, Atrial Fibrillation, Type II Diabetes mellitus, Muscle Wasting and Atrophy and Generalized Weakness.R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired.
This same MDS documents R2 is dependent on staff for personal hygiene, toileting and requires maximum assistance for transfers.
On 5/23/26 continual observations were made from 8:45 AM to 10:53 AM of R2 when V14 and V23 Certified Nurse Aide (CNA) assisted R2 to her room. R2 was sitting in her wheelchair facing the wall sized window in the resident common area across from the nurses station the entire time with no staff assistance of any kind.On 5/23/26 at 10:53 AM V14 and V23 Certified Nurse Aide (CNA) transferred R2 into her bed using a total body mechanical lift and then provided incontinence care.
V14 and V23 CNA's did not change their gloves or perform hand hygiene throughout the entire process. R2 was incontinent of urine and bowel. R2's bilateral Ischial Tuberosities and Coccyx had baseball sized dark reddened areas. R2's buttocks showed multiple red lines/wrinkled areas from sitting on the total body mechanical lift sling for an extended period of time. R2's odor has an extremely foul odor that permeated the room. On 5/23/26 at 11:10 AM V14 Certified Nurse Aide (CNA) stated she provided incontinence care at 7:30 AM and then assisted R2 to the dining room for breakfast. V14 stated R2 had not been assisted with any cares since 7:30 AM. V14 CNA stated she should have provided incontinence care every two hours but got busy and did not have time to check on R2. V14 CNA stated R2's urine has had a strong foul odor for a long time. On 5/24/26 at 3:20 PM V2 Director of Nurses (DON) stated the facility expectation is to follow the standard of practice for incontinence care. V2 DON stated all residents who are not able to voice their toileting needs and who are incontinent of bladder and bowel should be provided incontinence care every two hours and as needed. V2 DON stated the staff would not know if the resident is incontinent or not if the staff are not checking them. V2 DON stated even if the resident is continent at the two hour mark the staff would still need to reposition those residents to help reduce the risk of pressure ulcers from sitting in the same place too long.
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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.