Doctors Nursing & Rehab Center

F 0584

discoloration.The facility's 7/30/25 Daily Census Report documented 58 residents residing in the facility.

Level of Harm - Actual harm Residents Affected - Some

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

Event ID:

Facility ID:

If continuation sheet

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

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Doctors Nursing & Rehab Center

1201 Hawthorn Road Salem, IL 62881

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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, interview, and record review, the facility failed to maintain a temperature of less than 70 degrees Fahrenheit in the dietary dry storage area in accordance with facility policy. This failure has the potential to affect all 58 residents residing in the facility.Findings include:On 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.

Event ID:

Facility ID:

If continuation sheet

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

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Doctors Nursing & Rehab Center

1201 Hawthorn Road Salem, IL 62881

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 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on interview, and record review the facility failed to ensure the facility was administered and operated in a manner to ensure the safety and overall wellbeing for all 58 residents residing in the facility.Findings include:On 8/1/25 at 2:26 PM, V1 (Former Administrator) said he had emailed and called corporate several times about the HVAC (Heating, ventilation, and Air Conditioning) units 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.

Residents Affected - Many

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

Event ID:

Facility ID:

If continuation sheet

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

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Doctors Nursing & Rehab Center

1201 Hawthorn Road Salem, IL 62881

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 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to provide a functioning call light system for 3 (Resident R2, Resident R3, and Resident R4) of 6 residents reviewed for resident call system in the sample of 6.Findings include:Resident R2's Resident Face Sheet documented an admission date of 2/21/18 and included diagnoses of hemiplegia following cerebral infarction, vascular dementia, and need for assistance with personal care. Resident R2's Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment.Resident 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. Resident R3's MDS dated [DATE REDACTED] documented a BIMS score of 9, indicating moderate cognitive impairment.Resident 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. Resident R4's MDS dated [DATE REDACTED] documented a BIMS score of 15, indicating Resident 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 Resident R2, Resident R3, and Resident R4's reside.On 7/30/25 at 11:08 AM, Resident R2, Resident R3, and Resident R4 were in the same shared room and had hand bells on their over bed tables. Resident R4 stated that Resident R2, Resident R3, and Resident R4 had the hand bells because the call light was not working in their room. Resident R4 said her call light had stopped working about a week prior to this investigation. Resident 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. Resident R3 said she had been told

the facility was waiting on parts to fix it. Resident R4 said up until her call light stopped working, she would use her call light if Resident R3 needed something. Resident R2, Resident R3, and Resident 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 Resident R2, Resident R3, and Resident 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 Resident R2, Resident R3, and Resident 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, Resident R4 said when the facility has the industrial fans running, Resident 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 Resident R2, Resident R3, and Resident 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 Resident R2, Resident R3, and Resident 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 Resident R2's call light had stopped working. V8 said she comes to the facility to visit Resident R2 every Sunday and on 7/27/25, V8 saw a hand bell sitting on Resident R2's bedside table. V8 said she had questioned why Resident R2 had a hand bell and was told by staff Resident 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 Resident 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.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet