Silvis Center for Nursing Rehab & Care

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered, at ordered times for 5 of 8 residents (R1, R2 R3, R4 and R5) reviewed for medication administration in the sample of 8.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure a resident with declining mobility and signs and symptoms of a urinary tract infection was started timely on antibiotic treatment and was care planned for urinary tract infection monitoring and an increase in care needs for one of three residents (R1) reviewed for urinary tract infections in the sample of nine. These failures resulted in R1 suffering suprapubic pain and burning with urination, blood and odor in the urine and waiting seven days to receive treatment for a contagious bacterial urinary tract infection. Findings Include:The facility's Algorithm for the Antimicrobial Management of Urinary Tract Infections in Older Adults document (undated), documents Patient presents with new signs and symptoms of UTI (Urinary Tract Infection): [...]

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to ensure sufficient staff were available to meet the needs of the residents. This failure has the potential to affect all 73 residents currently residing at the facility.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure a resident with increased confusion and a resident with a diagnosis of lung cancer were taken to scheduled neurology and pulmonology specialist appointments for two of three residents (R1, R2) reviewed for physician appointments in the sample of nine.

Inspectors wroteBased on interview and record review the facility failed to answer call lights in a timely manner. This failure has the potential to affect all 76 residents who reside in the facility. The Facility's Call Lights: Accessibility and Timely Response policy dated August 2025 documents the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure an appropriate response. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. The Facility's Grievance Log documents that on 8/6/25 R2 complained about long call lights. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to serve their posted menu on a consistent basis. This failure has the potential to affect all 76 residents who reside in the facility. The Facility's Dietary Manager Job Summary documents it is the the Dietary Manager's responsibility to plan menus with the dietitian that meet the nutritional needs of residents in accord with recommended dietary allowances and state and federal regulations. Prepares standard recipes and daily production sheets from each menu cycle for dietary staff who prepare food-as applicable. Ensures menus are available to all residents and posts in readily accessible places in facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to revise a resident's care plan and include interventions to reduce risk for injury for one of three residents (R1) who frequently becomes physical causing self-harm or harm to others, in a sample of four. Findings Include:The facility's Change in Condition Guidelines policy dated May 2025 documents, All facility staff must remain alert to changes in condition in all residents. Upon recognition of a change, appropriate nursing and medical interventions must be initiated promptly to address the resident's needs. The interdisciplinary team will ensure the change is assessed, documented, and communicated according to federal and state guidelines . 6. Interdisciplinary Review and Follow-Up: Review the residents care plan to determine if updates are necessary. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure daily weights were completed as ordered for a resident with congestive heart failure and failed to identify an increase in weight for a resident with congestive heart failure for 1 of 3 residents (R1) reviewed for weights in the sample of 9. This failure resulted in R1's weight not being monitored appropriately, changes not being communicated with the physician, and R1 being transferred to the acute care hospital for treatment of congestive heart failure exacerbations on 4/3/25 and 4/10/25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with an order for a BiPAP (Bilevel Positive Airway Pressure) machine was provided one for 1 of 3 residents (R1) reviewed for respiratory devices in the sample of 9. This failure resulted in R1 being hospitalized for respiratory failure due to not using BiPAP machine.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient staffing to provide dependent residents with cares for 5 of 5 residents (R4, R6, R7, R8, R9) reviewed for staffing in the sample of 9.

Inspectors wroteBased on record review and interview the facility failed to only allow residents in the resident council meeting, failed to record attendance at resident council meeting minutes, failed to identify residents who had concerns during resident council meeting minutes and failed to resolve concerns voiced in the resident council meeting. These failures have the potential to affect all 62 residents who currently reside in the facility. Findings Include: The Illinois Long Term Care Ombudsman Resident Council Tool Kit for Staff Liaison documents A resident council is an independent group of long term care facility residents who typically meet at a minimum of once a month to discuss concerns and suggestions in the facility and to plan activities that are important to them. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure resident privacy was protected by not closing the door, during nursing care, for one resident (R262) of 16 residents (R5, R8, R18, R20, R21, R34, R35, R39, R40, R45, R268, R312, R313, R314, and R315), reviewed for privacy, in a total sample of 29.

Inspectors wroteBased on record review and interview the facility failed to reweigh a resident after a significant change for one resident (R8) of three residents reviewed for weight change in a total sample of 29. Findings Include: R8's Medical Record documents her weight on 11/3/24 as 125.8 pounds. R8's Medical Record documents her weight to be 173 pounds on 11/22/24 and again on 12/1/24. R8's Progress Note dated 12/27/24 documents that the Registered Dietician did not make any new recommendations for R8's diet because she questioned the accuracy of the weight. Registered Dietician documented This weight was possibly done with her wheelchair. On 3/19/25 at 2:25 PM V2 (Director of Nursing) stated (R8) did not have any significant weight gain. She should have been reweighed after the 11/22/24 weight of 173. [...]

Inspectors wroteBased on record review and interview the facility failed to attempt a gradual dose reduction of a psychotropic medication for one resident (R39) of five residents reviewed for unnecessary medications in a total sample of 29. Findings Include: The Facility's Psychotropic Drugs Usage policy dated 11/2017 documents Psychotropic drug use is based upon the comprehensive assessment of the resident. Psychotropic medications are given as necessary to treat a specific condition that is diagnosed and documented. Residents receiving psychotropic medications will have gradual dose reductions and behavioral interventions implemented unless contraindicated. The Facility's Psychotropic Drugs Usage policy dated 11/2017 documents Dosage reduction of antipsychotics, anxiolytics, and hypnotics are attempted per CMS guidelines unless clinically contraindicated. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure medications were administered timely to 5 of 5 residents (R1-R5) reviewed for medication administration in the sample of 5.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure call lights were responded to in a timely manner for 8 of 8 residents (R1, R2, R3, R8, R9, R10, R12 and R13) reviewed for improper nursing care in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to ensure safe positioning in a wheelchair was provided during care of a resident. This failure resulted in R1 sliding out of her wheelchair, being lowered to the floor, and sustaining a fracture of her left leg on 6/6/24.

Inspectors wroteBased on interview and record review the facility failed to provide/have the Medical Director attend (QA) Quality Assurance meetings. This failure has the potential to affect all 72 Residents who resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist, who is responsible for assessing, developing, implementing, monitoring, and managing the Infection Prevention and Control Program (IPCP) was certified. This has the potential to affect all 72 residents living in the facility.

Inspectors wroteBased on record review and interview the facility failed to attempt a gradual dose reduction, failed to identify target behaviors, failed to document any behaviors to justify the use of psychotropic medications, and failed to attempt nonpharmacological interventions for four (R27, R28, R39 and R48) of five residents reviewed for unnecessary medications in a total sample of 39. Findings Include: The Facility's Psychotropic Medication Use-Routine/PRN (As needed) policy dated 5/2024 documents (This facility) use of psychotropic medications will be based on a comprehensive assessment of a resident. Each (facility) must ensure that psychotropic medications will be monitored for proper dose including duplicate therapy, duration, evidence of adequate monitoring for efficacy and adverse consequences and to prevent identify and respond to adverse consequences. [...]

Inspectors wroteBased on record review, interview and observation the facility failed to perform hand hygiene during cares for two residents (R27 and R54) of 15 residents reviewed for infection control procedures in a total sample of 39.

Inspectors wroteBased on observation, interview and record review, the facility failed to incorporate hospital discharge cervical neck brace and skin care instructions into the care plan and treatment plan for one resident (R65) of six residents reviewed for skin care in the sample of 39.

Inspectors wroteBased on record review and interview the facility failed to have all doors alarmed at all times. This failure has the potential to affect all residents who wander (R1, R25, R33, R34, R39, R48 and R54) Findings Include: The Facility's Elopement Precautions Policy dated 4/2023 documents It is the policy of (this facility) to promote safety for all residents and to control potential elopement and wandering of our residents. Resident will be assessed for potential for eloping or wandering upon admission and periodically thereafter, with a minimum of annual evaluations. The resident care team will be advised and the at risk resident will be placed on elopement prevention. The Elopement Precautions policy documents the definition of Elopement as a resident leaving without permission. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure showers were provided to four residents (R1, R3, R5, and R6) of six residents reviewed for weekly showers, in a total sample of six.

Inspectors wroteBased on Interview and Record Review, the facility failed to protect a resident from misappropriation of narcotic pain medication for one of three residents (R1) reviewed for misappropriation in the sample of five.

Inspectors wroteBased on Interview and Record Review, the facility failed to administer a scheduled narcotic pain medication to a newly admitted post closed reduction right hip surgery resident for one of three residents (R1) reviewed for medication in the sample of five.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform hand hygiene during wound care for two of two residents (R36 and R58) reviewed for wound care in a sample of 28.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a medical indication and consistent adverse behaviors were documented to warrant the use of an antipsychotic medication for one of five residents (R40) reviewed for unnecessary medications in the sample of 28.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a physician-ordered special diet for one of one resident (R41) reviewed for special diets in a sample of 28.