Gillespie Health & Rehab Ctr

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interview the facility failed to initiate a physician ordered antibiotic timely for 1 of 1 resident (Resident R2) reviewed for Urinary Tract Infection (UTI) in the sample of 4.Findings include:1. On 9/17/2025 at 8:59AM Resident R2 stated she had symptoms of Urinary Tract Infection (UTI) and a specimen to the lab and results had been sent to the physician, but (the physician) was in the hospital. Resident R2 stated she was not receiving an antibiotic for a UTI. Resident R2 stated she has had UTI's in the past and septic. Resident R2's culture report dated 9/15/2025 documents greater than 100,000 Eschericia Coli in urine. Resident R2's report (faxed back to the facility from the physician) documents Macrobid (antibiotic) 100 milligrams (mg) twice a day (BID) x10 days dated 9/16/2025. Resident R2's Medication Administration Records dated 9/16/25 did not document the initiation/administration of physician ordered Macrobid. Resident R2's current face sheet dated 9/17/2025 documents Resident R2 has a diagnosis in part of chronic kidney disease, stage 4 (severe), and personal history of urinary tract infection. On 9/17/2025 at 12:44PM V1, Administrator stated the facility had notified the physician and the report with the order had been faxed to the facility and Resident R2 would be provided initial dose from convenience box. V1 stated she would expect the facility to follow up on lab results to ensure orders are received.The facility policy Test results dated 7/1/23 documents the resident's physician will be notified of the results of diagnostic tests. The policy documents results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility. The policy documents should the test results be provide to the facility, the attending physician shall be promptly notified of the results. The policy documents the Director of Nursing (DON), or charge nurse receiving the test results, shall be responsible for notifying the physician of such results.The facility policy Culture Testing dated 7/2/23 documents should the attending physician order cultures, they shall be obtained and completed as soon as practical. The policy documents all test results shall be reported to the physician as soon as the results are obtained.

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Gillespie Health & Rehab Ctr

7588 Staunton Road Gillespie, IL 62033

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to provide complete incontinent and peri care to 3 of 3 residents (Resident R1, Resident R2, and Resident R3) reviewed for incontinent care in the sample of 4. Findings include: 1.On 9/17/2025 Resident R2 placed on bedpan per V6 and V7, Certified Nursing Assistants (CNA'S). Resident R2 voided on the bedpan. Both V6 and V7 removed bedpan from under Resident R2. V6, CNA cleansed Resident R2's bilateral groin, inner thighs, wiped peri area front to back. V6 did not separate Resident R2's labia. V6 rinsed and dried all areas, prior to V6 and V7 turning Resident R2 on side to cleanse buttocks and rectal area. Resident R2's current face sheet dated 9/17/2025 documents Resident R2 has a diagnosis in part of chronic kidney disease, stage 4 (severe), and personal history of urinary tract infection. Resident R2's urine Culture results dated 9/15/2025 documents equal or greater 100,000 Escherichia Coli. Resident R2's Care plan dated 5/11/2023 documents Resident R2 is at risk for impaired skin/ deep tissue injury related to immobility, obesity, incontinence of bowel and bladder. Resident R2's Care plan documents intervention dated 3/26/2019; provide incontinence care after each episode according to facility policy.Resident R2's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R2 is cognitively intact. 2. On 9/17/2025 at 10:59AM

during incontinent care V7, CNA cleansed left groin, then right groin. V7, CNA took soaped cloth and wiped down front of Resident R1's peri area. V7 did not separate the labia. V7 then rinsed area and dried. Resident R1's MDS dated [DATE REDACTED] document Resident R1 is cognitively intact. Resident R1's MDS documents Resident R1 is always incontinentR1's Care plan dated 8/7/2025 documents Resident R1 is at risk for impaired skin to impaired mobility and incontinence. Resident R1's care plan documents intervention to provide incontinent care after each episode according to facility protocol. 3.

On 9/17/2025 at 1:27PM during incontinent care to Resident R3. V3, CNA after cleansing Resident R3's front. V5, CNA turned Resident R3 to left side. V3 with soaped cloth cleansed buttocks, then with clean soaped cloth took cloth and cleansed rectal area going from rectum to peri area, V3 then got a clean wet cloth and rinsed Resident R3 going from rectal area to peri area.Resident R3's MDS dated [DATE REDACTED] documents Resident R3 is always incontinent Resident R3's Care plan dated 12/28/2021 documents Resident R3 is at risk for ADL self-care Performance Deficit with intervention dated 12/28/2021 Resident R3 is frequently incontinent of urine and requires extensive assistance with toileting.On 9/17/2025 at 1:55 PM V3, CNA stated when providing peri care cleansing is to be done going from the front to the back. On 9/18/2025 at 10:33 AM V2, Director of Nursing (DON) stated she would expect staff to provide complete peri care and incontinent care. The facility policy Perineal Care Procedure, undated, documents the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The procedure documents to fill

the basin one half full of warm water. The procedure documents for a female resident: wash perineal area, wiping from front to back; separate labia and wash downward front to back. The procedure documents wash

the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks.

Event ID:

Facility ID:

If continuation sheet