A list of the most recent deficiencies for Illini Heritage Rehab and Hc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-15 | 2024-03-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-15 | 2024-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-15 | 2024-03-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-10-07 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-09-20 | 2023-10-07 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-20 | 2023-10-07 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-08-05 | 2023-08-28 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-08-05 | 2023-08-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-29 | 2023-07-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-07-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-26 | 2023-07-01 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-04-26 | 2023-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-26 | 2023-07-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-26 | 2023-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-10 | 2023-06-08 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-10 | 2023-06-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-10 | 2023-06-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-10 | 2023-06-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-10 | 2023-06-08 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-05-10 | 2023-06-08 | Y |
| Post nurse staffing information every day. | Health | 2023-05-10 | 2023-06-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-10 | 2023-06-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-13 | 2023-06-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-04-13 | 2023-06-08 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-13 | 2023-06-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-26 | 2023-06-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-26 | 2023-06-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-26 | 2023-06-08 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-26 | 2023-06-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-26 | 2023-06-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-26 | 2023-06-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-26 | 2023-06-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-26 | 2023-06-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-26 | 2023-06-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-26 | 2023-06-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-26 | 2023-06-08 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-26 | 2023-06-08 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-04-26 | 2023-06-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-26 | 2023-06-08 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-04-26 | 2023-06-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-06-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-04-26 | 2023-06-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-25 | 2023-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Develop a communication plan. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-16 | 2023-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-31 | 2023-02-14 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-01-31 | 2023-02-14 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-31 | 2023-02-14 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-01-31 | 2023-02-10 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-31 | 2023-02-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-07 | 2023-02-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-07 | 2023-02-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-07 | 2023-01-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-07 | 2023-01-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-09 | 2022-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-30 | 2022-10-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-10 | 2022-10-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-22 | 2022-10-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-11 | 2022-10-25 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-08-10 | 2022-10-04 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-07-22 | 2022-10-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-06 | 2022-05-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-02 | 2022-05-06 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-02 | 2022-05-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-02 | 2022-05-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-02 | 2022-05-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-02 | 2022-04-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-02 | 2022-04-08 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-03-02 | 2022-04-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-02 | 2022-04-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-03-02 | 2022-04-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-02 | 2022-04-08 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-03-02 | 2022-04-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-02 | 2022-04-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-02 | 2022-04-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-02 | 2022-04-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-02 | 2022-04-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-02 | 2022-04-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-02 | 2022-04-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-02 | 2022-04-08 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-03-02 | 2022-04-08 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-02 | 2022-04-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-03-02 | 2022-04-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-02 | 2022-04-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-02 | 2022-04-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-02 | 2022-04-08 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-03-02 | 2022-04-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-03-02 | 2022-04-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-02 | 2022-04-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-02 | 2022-04-08 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-02 | 2022-04-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-02 | 2022-04-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-08 | 2022-03-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-08 | 2022-03-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-08 | 2022-03-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-29 | 2022-01-26 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-03-30 | 2021-05-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-30 | 2021-05-07 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-03-30 | 2021-04-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-03-30 | 2021-04-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-30 | 2021-04-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-03-30 | 2021-04-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-30 | 2021-04-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-03 | 2021-03-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-03 | 2021-03-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-03-03 | 2021-03-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-03 | 2021-03-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-03 | 2021-03-26 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-03-03 | 2021-03-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-03 | 2021-03-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-03-03 | 2021-03-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-03 | 2021-03-26 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-03-03 | 2021-03-26 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-03-03 | 2021-03-26 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-03-03 | 2021-03-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-03 | 2021-03-26 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-03-03 | 2021-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-03 | 2021-03-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-03-03 | 2021-03-26 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-03-03 | 2021-03-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-03-03 | 2021-03-04 | N |
