The inspection was triggered by a complaint, not a routine survey.
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The inspection, completed August 12, 2025, stemmed from a complaint.
Inspectors classified the violation as isolated, with no documented actual harm, but with potential for more than minimal harm to residents.
The facility sits in Salem, a small city in southern Illinois.
The violation, tagged under F0677 and covering basic personal hygiene and grooming services, was cited at the minimal harm level.
In a nursing home, they are among the most preventable harms.
Inspectors classified it as an isolated problem with no documented harm, but with potential for more than minimal harm to residents.
The citation, issued August 12, covered catheter care and the broader management of residents who are incontinent, whether of bladder or bowel.
Inspectors cited the facility for failing to provide a working call system to a resident who had ended up on the floor.
The inspection, conducted August 12, 2025, centered on a single resident identified in records as Resident 4.
The citation was classified as an isolated deficiency, meaning inspectors did not find it playing out across the resident population.
The answer, inspectors concluded, was not clearly yes.