Doctors Nursing & Rehab Center

serve food in accordance with professional standards.

less than 70 degrees Fahrenheit in the dietary dry storage area in accordance with facility policy.

7/30/25 at 10:03 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. On 7/30/25 at 11:08 AM, V5 (Dietary Manager) said the dietary dry storage area did not have a functioning Heating, Ventilation, and Air Conditioning (HVAC) unit and had been very hot since the start of summer 2025.

Using the calibrated thermometer, the ambient air temperature in the dietary dry storage area was observed to be 90.6 degrees Fahrenheit.On 7/30/25 at 12:06 PM, V4 (Maintenance Director) said he had notified the HVAC company of the HVAC system not functioning in the dietary dry storage area and was told the HVAC company would not be coming to the facility until the facility paid the bill for the last time the HVAC company had performed work for the facility in December 2024.On 8/1/25 at 2:26 PM, V1 (Former Administrator) said he had been asking corporate to fix the HVAC system in the dietary dry storage area for 1 year and 1 month.The facility's January 2012 Dry Storage Areas policy documented in part .

Dry storage areas will be kept neat, orderly, and in a condition which protects foods in a safe and sanitary manner. 1.

Non-perishable foods will be stored in a dry area with temperatures that do not exceed 70 F.The facility's 7/30/25 Daily Census Report documented 58 residents residing in the facility.

145247 08/12/2025

Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881

facility.Findings include:On 8/1/25 at 2:26 PM, V1 (Former Administrator) said he had emailed and

PTAC (Packaged Terminal Air Conditioner) systems not working but didn't hear anything back from them. V1 said he did not have the authority to change the HVAC units, that was a corporate decision.

V1 said he had been asking corporate to fix the HVAC unit in the dietary dry storage area for 1 year and 1 month prior to this investigation. V1 said he had notified corporate of the dining room floors needing to be replaced but had not been given approval to fix them.On 7/30/25 at 12:06 PM, V4 (Maintenance Director) said he had been told by the HVAC company they would not return to the facility to fix the HVAC units until their bill had been paid from December 2024. V4 said he had requested from corporate 33 PTAC units for resident rooms and had only been sent 4 PTAC units. V4 said he was aware there was a room where residents residing that did not have a functioning call light system. V4 said he had called the company that fixes the call lights and had been told the company would not come to the facility until their bill was paid.On 8/6/25 at 11:16 AM, V12 (Regional Director of Operations) said corporate was not aware of any of these issues.The facility's 7/30/25 Daily Census Report documented 58 residents residing in the facility.

145247 08/12/2025

Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881

for 3 (R2, R3, and R4) of 6 residents reviewed for resident call system in the sample of 6.Findings

of hemiplegia following cerebral infarction, vascular dementia, and need for assistance with personal care. R2's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment.R3's Resident Face Sheet documented an admission date of 8/23/24 and included diagnoses of chronic respiratory failure and history of cerebral infarction. R3's MDS dated [DATE] documented a BIMS score of 9, indicating moderate cognitive impairment.R4's Resident Face Sheet documented an admission date of 12/21/23 and included diagnoses of other motor neuron disease, respiratory failure, and chronic pain. R4's MDS dated [DATE] documented a BIMS score of 15, indicating R4 was cognitively intact.On 7/30/25 at 10:20 AM, there were large, loud industrial fans running at both ends of the hall where R2, R3, and R4's reside.On 7/30/25 at 11:08 AM, R2, R3, and R4 were in the same shared room and had hand bells on their over bed tables. R4 stated that R2, R3, and R4 had the hand bells because the call light was not working in their room. R4 said her call light had stopped working about a week prior to this investigation. R3 said her call light had not been working for a couple months prior to this investigation but was unsure of the exact date it stopped working. R3 said she had been told the facility was waiting on parts to fix it. R4 said up until her call light stopped working, she would use her call light if R3 needed something. R2, R3, and R4's call lights were tested and none were noted to be working.On 7/30/25 at 12:06 PM, V4 (Maintenance Director) said he was aware R2, R3, and R4's call lights were not working. V4 said he had called the company that fixed the facility's call lights and was told they would not come to the facility due to the facility not paying their bill.On 7/30/25 at 12:12 PM, V1 (Former Administrator) said he was not aware the call light company was not coming to fix R2, R3, and R4's call light due to the bill not being paid, and would contact corporate for direction.On 8/6/25 at 10:32 AM, R4 said when the facility has the industrial fans running, R4 has to ring her hand bell for long periods of time because she assumed staff could not hear her bell over the fans.On 8/6/25 at 11:40 AM, V6 (Licensed Practical Nurse/LPN) said when the industrial fans were running, they were so loud staff could barely hear the phone ringing and if staff were down the hall away from R2, R3, and R4's room, staff would not be able to hear their hand bells ringing.On 8/7/25 at 1:20 PM, V7 (Certified Nursing Assistant/CNA) said when the industrial fans were running, there was no way staff could hear R2, R3, and R4's hand bells if staff were down the hall or at the nurse's station. On 8/1/25 at 10:14 AM, V8 (Family Member/Power of Attorney/POA) said she was not sure when R2's call light had stopped working. V8 said she comes to the facility to visit R2 every Sunday and on 7/27/25, V8 saw a hand bell sitting on R2's bedside table. V8 said she had questioned why R2 had a hand bell and was told by staff R2's call light was not working. V8 said the facility was having trouble with their air conditioning and had large industrial fans running. V8 said when the industrial fans were running staff could not hear R2's hand bell ringing.The facility's July 2014 Answering the Call Light policy documented in part .7.

Report all defective call lights to the nursing supervisor promptly.On 8/12/25 at 8:52 AM, V9 (Administrator) said she had asked corporate for a functionality of the call light policy and what to do if it wasn't working on 8/8/25 but was told they could not find one.