Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Haven Of Farmer City during CMS and state inspections, most recent first.
Unqualified Director of Food and Nutrition Services: The Dietary Manager was supervising kitchen operations and stated they were the full-time food service manager, but they were not a clinically qualified CDM/CFPP, had no equivalent training, and denied meeting IL standards or having clinical nutrition qualifications. The facility assessment said a Dietician or other clinically qualified nutrition professional would serve as the director of food and nutrition services, and the facility had 48 residents. During the survey period, the facility also failed to sanitize dishes effectively, prevent ice cross-contamination, and serve therapeutic diets as ordered.
Improper Dish Sanitizing and Ice Contamination: A Dietary Aide was washing dishes in a mechanical dishwasher that tested at 0 ppm sanitizer, despite the unit’s label requiring 50-100 ppm, and the sanitizer bucket supplying the machine was empty. In addition, the kitchen ice machine had missing and peeling plastic at the ice bin edge, mineral deposits from overflow were present, and the DMgr acknowledged the plastic was contaminating the ice.
Failure to Provide Ordered Therapeutic Diets and Supplements: A resident with DM, a pressure wound, and significant wt loss did not receive ordered SF ice cream, and the meal ticket did not reflect the full physician order. The Dietary Manager stated the facility did not have residents on therapeutic diets, while the kitchen used no LCS-specific spreadsheet and served the same beverages and full dessert portions to residents ordered LCS diets. In addition, multiple residents ordered mechanical soft diets, including residents with dysphagia, hemiplegia, and cerebral infarction, were observed eating regular texture foods instead of the ordered texture, and the lunch meal did not include the ground meat item listed on the dietary spreadsheet.
Failure to maintain resident dignity during dining: three CNAs were observed feeding non-verbal residents in the assisted dining room while engaging in extensive personal conversations with each other about unrelated topics, and only minimally speaking to the residents. Staff later acknowledged that talking with each other instead of the residents during feeding was a dignity issue, and the DON/Administrator was informed of the concern.
Advance directives and code status were inconsistently documented for two residents. One resident’s POA for health care directed limits on life-sustaining treatment, but the EMR banner and POS listed Full Code while the care plan listed DNR, and the paper chart also had a DNR sticker. Another resident had no code status documented in the EMR banner, POS, or care plan, although the paper chart had a Full Code sticker; staff and the regional nurse consultant confirmed the mismatched or missing documentation.
A resident was discharged from Medicare Part A services before all covered benefit days were used, but the record did not show the required NOMNC or ABN. The BOM said the notices were not needed because the resident waived benefits, while the Administrator stated a NOMNC should have been issued because the facility initiated the discharge and skilled benefit days remained.
A resident with documented MH diagnoses, including schizoaffective disorder and recurrent major depressive disorder, had an exempt hospital discharge PASRR Level I screen approved for 30 days. The resident remained in the facility after the exempt period ended without the required new PASRR screen, and the Administrator confirmed the screen should have been completed for the continued stay.
Failure to Develop Comprehensive Care Plan for Insulin and Anticoagulant Use: A resident had active orders for Xarelto and insulin glargine plus insulin lispro, but the care plan did not address anticoagulant or insulin use and monitoring. The facility policy required an individualized comprehensive care plan with measurable objectives and timetables, and the RN consultant confirmed the resident did not have a comprehensive care plan in place.
A resident with an indwelling urinary catheter, cerebral palsy, obstructive uropathy, BPH, kidney atrophy, and a history of UTIs was observed asleep in a low bed with the catheter drainage bag lying on the floor and the tubing coiled on the floor under the bed. The bag had no protective cover and contained dark yellow urine. A CNA confirmed the bag was on the floor, and the facility protocol stated the drainage bag must never touch the floor.
Respiratory equipment was repeatedly left soiled and not maintained for two residents receiving O2, BIPAP, and neb txs. An LPN observed empty humidifier bottles, undated and soiled BIPAP and neb masks/tubing, and dated oxygen tubing that had not been changed per order or facility policy. One resident stated the equipment had not been changed recently and the water bottle had been empty since the prior day; the other stated staff rarely filled the bottle or changed the tubing as ordered.
Failure to Offer and Administer Influenza Vaccine: A resident with COPD was not offered or given the annual influenza vaccine despite documented POA consent and an immunization record showing the last flu shot was over a year earlier. There was no documentation of any attempts to provide the vaccine, and an RN consultant stated the resident was missed during the facility vaccine clinic.
Failure to offer and document COVID-19 vaccination for a resident with COPD. The resident’s record showed prior COVID-19 vaccination and verbal consent from the POA, but there was no documentation of any attempt to provide the vaccine. The RN consultant stated the resident was missed during the vaccine clinic and should have received the vaccine per CDC guidance.
A resident with multiple conditions including dementia, CKD stage 3, and type 2 DM with hyperglycemia refused a blood glucose (BG) check and insulin, but an LPN, citing the POA’s wishes, obtained the BG and administered insulin despite the refusal. According to CNAs, this occurred in the dining room, where the LPN pulled back the resident’s cover, exposed the arm, and gave the injection without privacy, after which the resident stated that her rights were violated. The DON confirmed that residents have the right to refuse care and that BG checks and insulin injections should not be done against a resident’s wishes or without privacy.
A deficiency was cited when a nursing home area was found to have accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
A resident with diabetes and a foot wound was discharged from a facility without a proper discharge plan, medication, or wound care supplies. The resident, who was unable to read or write, signed an AMA form and was taken to a homeless shelter. The facility did not consult the physician or make referrals to outside agencies. The resident later sought medical help and was admitted to a hospital for wound care.
The facility failed to monitor refrigerator and freezer temperatures and improperly stored utensils in food containers, potentially affecting all 44 residents. Temperature logs were incomplete, and utensils were found with handles in direct contact with food, violating facility policies.
The facility failed to notify the physician of a new pressure ulcer and nausea/stomach pain for two residents. A resident with high risk for pressure ulcers had an open area noted but the physician was not informed. Another resident with a history of wound infection complained of nausea, and although the nurse faxed the primary care provider, no further action was documented. The facility's policy requires prompt notification of changes in resident status.
A facility failed to ensure the least restrictive restraint was used for a resident with severe cognitive impairment. The resident was observed with multiple restraints, including a safety belt, busy tray, reclining wheelchair, and trunk supports, which were not fully addressed in the care plan. Staff indicated these were used to prevent falls, but the Director of Nursing and Administrator did not consider them restraints, despite being coded as such in the MDS.
A resident with Epileptic Syndrome and Mild Neurocognitive Disorder, who is dependent on staff for personal care, reported that staff did not assist with daily hygiene tasks such as brushing teeth and washing the face. The resident's hair was dirty, nails were unclean, and clothing was stained. The DON confirmed the resident sometimes refuses showers but should receive them weekly, and staff should assist with morning care. The facility's A.M. Care policy was not consistently followed.
A resident with a history of urinary tract infections did not receive proper infection control during catheter irrigation. An LPN failed to wash hands and cleanse the catheter connection site with antiseptic wipes, contrary to facility protocol. The oversight was acknowledged by the LPN during the procedure.
The facility failed to maintain sanitary conditions for respiratory care equipment for two residents. One resident had oxygen tubing on the ground and an empty humidifier bottle with residue. Another resident had oxygen tubing hanging with the nasal cannula touching the floor. The DON confirmed that staff should store tubing in plastic bags, refill humidifier bottles, and change equipment weekly, documenting these changes.
A facility failed to provide trauma-informed care for a resident with PTSD due to spousal abuse. Despite the facility's policy requiring such care, the resident's care plan lacked interventions for PTSD. Observations showed the resident was anxious without staff intervention. The Social Service Director and DON confirmed awareness of the PTSD diagnosis and the need for a care plan addressing triggers.
A facility failed to maintain a secure bed rail for a resident with a history of falling and behavioral disturbances, including Alzheimer's and bipolar disorder. The resident's bed rail was found to be extremely loose, creating a gap between the mattress and rail. The Maintenance Director acknowledged the issue and noted the resident's behaviors increased fall risk. Bed rails were not routinely checked unless new or if the resident moved, relying on staff to report issues. The Administrator confirmed the need for frequent checks due to the resident's condition.
A facility failed to dispose of a medication for a deceased resident as per its policy. During an inspection, Bisacodyl Suppositories labeled with the resident's name were found in the medication refrigerator. The DON confirmed the resident had expired and the medication should have been disposed of.
A facility failed to maintain a medication error rate below five percent, resulting in a 12% error rate. A resident received medications outside the one-hour window stipulated by the facility's policy. The medications, including Tramadol, Tylenol, and Gabapentin, were administered at 9:20 AM instead of the scheduled 8:00 AM time. The DON confirmed the acceptable administration window is one hour before and after the ordered time.
A facility failed to provide necessary dental services for a resident with Epileptic Syndrome and Mild Neurocognitive Disorder. Despite a physician's order for dental services, the resident's care plan did not address his dental needs. The resident reported not receiving assistance with dental hygiene and had not seen a dentist since admission, resulting in multiple broken teeth affecting his diet. Observations confirmed poor dental hygiene, and facility staff acknowledged the lack of regular dental services.
The facility failed to arrange dental services for a resident with broken dentures, despite the care plan indicating the need for dental health maintenance. The resident's family member repeatedly requested dental care, but the facility only provided ground food, which the resident disliked. The DON acknowledged that arrangements should have been made, as the resident had been at the facility for several years, and denied knowledge of any existing dental service arrangements.
A facility failed to maintain effective communication with a hospice provider, resulting in the absence of an up-to-date Hospice Plan of Care for a resident with dementia and Alzheimer's. The hospice RN did not document visits or changes in care in the communication binder, and the Resident Care Coordinator confirmed inadequate communication methods, violating the facility's agreement with the hospice provider.
The facility failed to make survey results easily accessible to residents, affecting all 44 residents. During a resident council meeting, residents were unaware of the State inspection book's location. The Administrator revealed it was placed on a top shelf, not at wheelchair eye level, and surrounded by other books, making it difficult to access. This does not comply with residents' rights to view facility review reports.
The facility failed to provide the services of a qualified director of food and nutrition services, impacting all 44 residents. The Administrator confirmed the absence of a qualified Dietary Manager since the previous one quit. A new Dietary Manager was hired and began work but was still undergoing training. The new manager was observed supervising meal service, and the facility's application confirmed 44 residents at the time.
Unqualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services. On 3/17/2026 at 9:58 AM, the Dietary Manager (V12) was actively supervising dietary operations in the kitchen and stated that they were the full-time manager of the food service as the person in charge. V12 reported not being a clinically qualified Certified Dietary Manager, not having equivalent training, and denied meeting Illinois standards for a food service manager or dietary manager. V12 also stated they had only completed a two-day food service sanitation course and had no instruction or qualifications in clinical nutrition. V12 further denied being a dietician, being a certified dietary manager, having an associate's or higher degree in food service management or hospitality, having 2 or more years of experience as a director of food and nutrition services in a nursing facility, graduating from an approved dietetic and nutrition program, completing a prior Illinois Department of Public Health approved course with the required classroom instruction and dietician consultation, or completing an ANFP-approved Certified Dietary Manager or Certified Food Protection Professional course. The Facility Assessment dated 4/10/2025 stated the facility would employ a Dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services, and the facility application documented 48 residents. During the survey period from 3/17/2026 through 3/19/2026, the facility also failed to effectively sanitize dishes, failed to prevent physical cross-contamination of ice, and failed to serve therapeutic diets as ordered.
Improper Dish Sanitizing and Ice Contamination
Penalty
Summary
The facility failed to effectively sanitize dishes in the kitchen mechanical sanitizing dishwasher. During observation, a Dietary Aide was washing multiple loads of dishes and tested the dishwasher sanitizer concentration with a chemical strip that showed zero parts per million. A Survey Agency test strip also showed zero sanitizer present. The dishwasher had a manufacturer nameplate stating that a minimum concentration between 50 and 100 parts per million of sanitizer was necessary to effectively sanitize dishes, and the five-gallon bucket of liquid sanitizer supplying the dishwasher was empty. The facility also failed to prevent physical cross-contamination of ice. The kitchen ice machine was observed with missing and deteriorated plastic along the front edge of the ice bin, including an approximately eight-inch missing section and two- and four-inch sections peeling into the bin. Mineral deposits were present along the sides and front of the evaporator/condenser above the ice bin, indicating condensate drain water had been overflowing down the sides of the ice machine instead of to the sewer and potentially entering the ice bin. On a later observation, the same section of plastic was still peeling inward and was in direct contact with the ice, and the Dietary Manager acknowledged that the plastic was contaminating the ice.
Failure to Provide Ordered Therapeutic Diets and Supplements
Penalty
Summary
The facility failed to provide physician-ordered therapeutic diets and supplements for multiple residents. R3 had a physician order for a low concentrated sweets (LCS) diet, pureed texture, thin liquids, and sugar free ice cream twice daily at lunch and supper, but on 3/18/26 the meal ticket did not reflect the complete order and the resident did not receive the sugar free ice cream or a substitute on the meal tray. The Dietary Manager confirmed the item was not available and stated the facility did not have a substitute and had not been able to purchase the sugar free ice cream. The Dietary Manager also stated the facility did not have any residents who receive therapeutic diets, despite the order listing showing multiple residents ordered LCS diets. The kitchen spreadsheets available to surveyors listed only texture modifications and did not include a specific diet spreadsheet for LCS diets. During observation, residents ordered LCS diets received the same beverages as other residents, including regular drink mixes, and all residents received the same dessert portion at lunch rather than reduced portions for LCS diets. The facility Dietician stated the facility had a specific menu spreadsheet for LCS diets and that residents on LCS diets should receive half-size dessert portions and sugar free beverages. The facility also failed to provide mechanical soft diet items as ordered. The dietary spreadsheet for Week 4 showed residents on mechanical soft diets should receive two ground Swedish meatballs at lunch, but none were prepared or served during the observed lunch meal. Several residents with physician orders for mechanical soft diets, including residents with diagnoses such as dysphagia, hemiplegia, and cerebral infarction, were observed eating regular texture food instead of the ordered mechanical soft texture. The Dietician stated Swedish meatballs need to be ground for residents who receive a mechanical soft diet.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to ensure residents' right to dignity while dining for three residents who were being fed in the assisted dining room. During the meal, three CNAs intermittently held extensive personal conversations with each other about topics unrelated to work, including pay at other facilities for agency CNAs, relatives' birthday activities, and a staff member's two-year-old child's behaviors, while they were actively feeding residents at the table. The CNAs minimally spoke to the residents they were assisting and mainly directed them only to take a bite or take a drink before returning to their own conversation. The three residents involved were non-verbal throughout the meal. One CNA stated that they should have been talking with the residents instead of visiting with each other, and the other two CNAs confirmed that talking with residents while feeding them, rather than with each other about outside interests, is a dignity issue. The Administrator stated she had been informed that some CNAs were talking to each other about outside interests in the assisted resident dining room when they should have been conversing with the residents they were assisting with the meal.
Advance Directives and Code Status Were Inconsistently Documented
Penalty
Summary
The facility failed to accurately document resident advance directives in the medical record for two residents reviewed for advance directives. For one resident, the Power of Attorney for Health Care dated 3/14/2025 and signed by the resident stated that life should not be prolonged and that life-sustaining treatment should not be provided or continued if the agent believes the burdens outweigh the expected benefits. However, the resident’s EMR banner and current Physician Order Sheet both listed the resident as Full Code, while the current Care Plan documented the resident as DNR. The resident’s paper medical record at the nurses’ station also had a DNR sticker on the binder. For the second resident, the EMR banner did not document any code status, and the current Physician Order Sheet and Care Plan also did not contain any code status. The paper medical record at the nurses’ station had a Full Code sticker on the binder, but no advance directives were formulated in either the EMR or paper medical record. During interviews, the resident’s POA stated the resident was full code and that the facility should have the paperwork to note that, while the RN stated staff look at the EMR banner and/or Physician Order Sheet to determine code status. The regional nurse consultant confirmed the first resident’s advance directives were mismatched and that the second resident had no advance directives formulated in the medical record.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage upon a resident’s discharge from Medicare Part A services. For one resident, the Beneficiary Notice-Residents discharged within the last six months form documented discharge from the facility and waiver of benefits, and the Beneficiary Protection Notification Review form documented that the resident initiated discharge from Medicare Part A services before all covered Medicare benefit days were used, but also documented that the required NOMNC was not received. The resident’s physical therapy discharge summary showed therapy services were provided until the resident reached the highest practical level/max potential achieved, and the medical record did not document receipt of either the NOMNC or the Advanced Beneficiary Notice of Non-Coverage after discharge from Medicare. The Business Office Manager stated the resident did not require a SNF ABN or NOMNC because benefits were waived, while the Administrator stated the resident should have been given a NOMNC because the facility initiated discharge from services and skilled benefit days remained.
PASRR Screening Not Completed After Exempt Status Expired
Penalty
Summary
The facility failed to arrange the required PASRR assessment to determine a resident’s need for nursing home and specialized services for serious mental illness after the 30-day exempt admission PASRR status expired. Resident R38 was admitted with documented mental health diagnoses including Schizoaffective Disorder and Unspecified Major Depressive Disorder, Recurrent, Unspecified, and the current diagnosis list also identified a mental health condition. The resident’s PASRR Level I screen outcome showed an exempted hospital discharge with 30 approved days and stated that if the resident needed to stay longer than 30 days, a new Level I screen had to be submitted by or before the 30th day after admission. The record review showed R38 continued to reside in the facility without the required new PASRR screen after the exempt status expired, and the Administrator confirmed that a new PASRR screen should have been completed for the continued stay.
Failure to Develop Comprehensive Care Plan for Insulin and Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident's insulin and anticoagulant use and monitoring. The resident's current physician orders included Xarelto 20 mg by mouth daily for anticoagulant use, insulin glargine-yfgn 45 units subcutaneously in the evening, and insulin lispro 10 units subcutaneously, but the resident's current care plan did not include anticoagulant medication use and/or monitoring or insulin use and/or monitoring. The facility's Care Plans (Comprehensive) Policy states that an individualized comprehensive care plan with measurable objectives and timetables is to be developed for each resident within seven days of completion of the comprehensive assessment. The resident's admission MDS was completed on 2/11/26, and on 3/20/26 the Regional Nurse Consultant stated the Regional MDS Coordinator is responsible for completing resident care plans and confirmed the resident did not have a comprehensive care plan in place.
Urinary catheter drainage bag and tubing left on floor
Penalty
Summary
The facility failed to maintain an indwelling urinary catheter drainage bag and tubing in a clean, sanitary manner and off the floor for one resident. R6 had diagnoses including spastic quadriplegic cerebral palsy, other obstructive and reflex uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, atrophy of kidney, and a personal history of urinary tract infections. R6's physician orders included changing the urinary catheter every 10 days on night shift and using an 18 French catheter with a 30 cc balloon. During observation, R6 was asleep in a low bed approximately one foot above the floor. The bedside indwelling urinary catheter drainage bag was lying flat on the floor on the right side of the bed without a dignity/protective drainage bag cover, and the catheter tubing was coiled on the floor under the bed. The drainage bag contained an undetermined amount of dark yellow urine. A CNA later confirmed the drainage bag was on the floor and stated that the catheter should be kept off the floor so it does not get contaminated with germs. The facility's Urinary Catheter Drainage Bag Protocol stated that the drainage bag must never touch the floor and that tubing should be arranged to prevent twisting, kinking, or looping.
Respiratory equipment left soiled and unmaintained
Penalty
Summary
The facility repeatedly failed to keep respiratory equipment in a clean and sanitary condition for two residents receiving oxygen therapy and inhalation treatments. The report identified soiled BIPAP masks and tubing, soiled nebulizer masks and tubing, empty oxygen humidifier water bottles, and oxygen tubing and nasal cannula equipment that were not maintained according to the facility policy requiring respiratory equipment to be cleaned, disinfected, replaced every seven days, and refilled as needed. R38 had orders for BIPAP at bedtime with supplemental oxygen, oxygen titration to maintain saturations above 90%, and PRN ipratropium-albuterol nebulizer treatments for shortness of breath related to COPD with acute exacerbation. During observation, R38 was using oxygen at 3 liters per nasal cannula via a bedside concentrator with an empty humidifier bottle attached, while a heavily soiled BIPAP mask and a soiled nebulizer mask were found on the bedside table without dates. R38 stated the masks had not been changed recently, that the equipment was dirty, and that the humidifier bottle had been empty since the day before. An LPN confirmed the BIPAP and nebulizer masks and tubing were undated and soiled, the humidifier bottle was empty, and stated she had forgotten to change the equipment and fill the bottle. R1 had an oxygen order and nebulizer therapy orders for COPD. During observation, R1 was in bed with oxygen at 3 liters per nasal cannula via a bedside concentrator, and the humidifier bottle was empty and undated. R1 also had a soiled nebulizer face mask on the bedside table, and the nebulizer tubing and oxygen tubing were dated 3/01/26. R1 stated the humidified oxygen was needed so the nose would not get sore and said nurses rarely filled the water bottle or changed the tubing as ordered. An LPN confirmed the humidifier bottle was empty and the nebulizer mask, tubing, and oxygen tubing were soiled and dated 3/01/26, and confirmed the respiratory equipment should have been changed according to the facility policy and physician order.
Failure to Offer and Administer Influenza Vaccine
Penalty
Summary
The facility failed to offer and administer an influenza vaccine to one resident who was reviewed for immunizations. The resident had a history of chronic obstructive pulmonary disease and was admitted to the facility on [DATE]. The resident’s immunization record showed the last influenza vaccine was received on 10/25/24, and an influenza vaccine consent form dated 8/18/25 documented that the resident’s power of attorney verbally consented for the resident to receive an annual influenza vaccine. However, there was no documentation in the resident’s medical record of any attempts to provide the influenza vaccine. During an interview on 3/20/26, the Regional Nurse Consultant stated the resident did not receive the influenza vaccine during the facility vaccine clinic and should have received it, and stated the facility follows current CDC vaccine guidelines. The facility’s influenza vaccine policy stated that all residents will be offered the influenza vaccine annually between October 1 and March 31 unless contraindicated, already immunized, or refused after education.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to offer and administer a COVID-19 vaccine to ensure one resident was up to date on immunizations. The resident’s face sheet documented admission to the facility, age, and a diagnosis of chronic obstructive pulmonary disease. The immunization record showed the resident’s last COVID-19 vaccine was received on 10/25/24, and a COVID-19 Vaccine Consent form dated 8/18/25 documented that the resident’s power of attorney verbally consented for the resident to receive a COVID-19 vaccine. However, there was no documentation in the resident’s medical record of any attempts to provide the vaccine. During interview on 3/20/26, the Regional Nurse Consultant stated the resident did not receive the COVID-19 vaccine during the facility vaccine clinic, was unsure why the resident was missed, and stated the resident should have received the vaccine. The report also cited CDC 2025-2026 COVID-19 vaccination guidance for adults 65 years and older who were previously vaccinated before the 2025-2026 vaccine.
Failure to Honor Treatment Refusal and Provide Privacy During Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to refuse treatment and to receive care in privacy during blood glucose monitoring and insulin administration. Facility policies on resident rights state that residents have the right to make their own choices and to request, refuse, or discontinue any treatment, and the Medication Administration policy states that residents may actively refuse medications. The resident involved had multiple diagnoses, including cerebral infarction, dysphagia following cerebral infarction, hypertension, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, chronic kidney disease stage 3, and type 2 diabetes mellitus with hyperglycemia. On the date of the incident, the facility’s incident report documented that the resident was refusing to have her blood glucose level taken, yet an LPN took the resident’s hand and obtained the blood glucose level while the resident was refusing, and then administered insulin after the resident had stated she did not want it completed. The LPN stated she was doing what the resident’s POA wanted done. A CNA reported that at breakfast the resident refused the blood glucose check and insulin, and that after an RN left the dining room, an LPN returned and stated that the POA wanted the blood glucose checked and insulin given. The CNA stated the LPN pulled the cover back from the resident, checked the blood glucose using blood obtained from the resident’s finger, left, then returned with a syringe, again pulled the cover back, peeled up the resident’s sleeve, and administered insulin, all while the resident had refused. The CNA reported that the resident then looked at another CNA and stated that her rights were violated. The DON stated that staff should not perform cares or medical tests such as blood glucose monitoring or administer medications if a resident does not want it done, and that nurses should not be checking blood glucose levels or injecting medications such as insulin in the dining room, emphasizing that residents should be provided privacy for medication administration.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could lead to accidents, and that supervision measures in place were insufficient to prevent such incidents. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Develop Discharge Plan for Resident
Penalty
Summary
The facility failed to develop a discharge plan for a resident, identified as R2, who required diabetic medication management and wound care. R2 was admitted to the facility from a hospital and had a history of homelessness. The facility's Transfer and Discharge Policy mandates that discharges should maintain continuity of care, but R2's medical record lacked a discharge plan or physician notification. R2 was discharged against medical advice (AMA) without proper planning or consultation with the physician or law enforcement, following the discovery of a past conviction that made him ineligible to stay at the facility. The facility administrator, identified as V1, informed R2 about the need to find alternative placement due to his conviction. R2, unable to read or write, was read the AMA paperwork and signed it, leading to his discharge to a homeless shelter without necessary medications or wound care supplies. R2 later sought medical assistance from a nurse practitioner, V12, who admitted him to the hospital for wound care. The facility did not make any referrals to outside agencies or initiate discharge planning, assuming the AMA discharge absolved them of further responsibility. R2's inability to manage his medical care was evident when he walked to the nurse practitioner's office for help, resulting in his hospital admission. The hospital social worker, V4, expressed concerns about R2's ability to manage his care at the shelter, as he required insulin and dressing changes. The nurse practitioner, V12, highlighted the risks posed by the facility's discharge process, emphasizing R2's vulnerability due to his medical conditions and lack of resources at the shelter.
Improper Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to adhere to its policies regarding food storage and temperature monitoring, which could potentially affect all 44 residents. Observations revealed that utensils were improperly stored in bulk food containers, with handles in direct contact with food items such as thickener, oatmeal, brown sugar, and hot cocoa. This practice is against the facility's Storage policy, which mandates that utensils should not be left in food containers to prevent contamination. Additionally, the facility did not consistently monitor and record the temperatures of the walk-in refrigerator and freezer as required by their Equipment Temperatures policy. The temperature logs for December 2024 were incomplete, with several days missing entries for both the morning and evening shifts. The Dietary Manager confirmed that the dietary staff should complete these logs twice daily and acknowledged the improper storage of utensils in food containers.
Failure to Notify Physician of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician of a new pressure ulcer and nausea/stomach pain for two residents. Resident 5, who is at high risk for pressure ulcers due to osteoarthritis, weakness, and incontinence, had an open area noted on the right coccyx on 12/8/24. The registered nurse applied a barrier and covered the area with an absorbent foam dressing but did not document further or notify the physician or responsible party as required by the care plan. The Resident Care Coordinator was unaware of the open area and stated that the nurse should have filled out a new skin sheet and notified the doctor. Resident 247, with a history of a wound infection related to a tibia/fibula fracture, complained of nausea and stomachache on 12/13/24. The nursing notes indicate that the nurse faxed the primary care provider about the change but did not document any further action or resolution regarding the nausea. The Director of Nursing stated that the nurse should have called the doctor or on-call nurse to obtain an order. The facility's policy requires prompt notification of changes in a resident's status to the appropriate parties.
Failure to Properly Assess and Document Restraint Use
Penalty
Summary
The facility failed to ensure the least restrictive restraint was used for the least amount of time for a resident identified as R8. The facility's policy on physical restraints, revised in 2018, mandates that residents should be free from physical restraints unless required for medical symptoms or therapeutic intervention. However, R8, who is severely cognitively impaired and has multiple diagnoses including dementia and anxiety, was observed with several restraints, including a self-releasing safety belt, a busy tray, a reclining seat wheelchair with bilateral trunk supports, and a lap tray. These devices were not fully addressed in R8's care plan, which only mentioned the seat belt. The care plan did not include the reclining wheelchair, trunk supports, or lap tray, and the facility's evaluation of restraint use did not cover these additional devices. During an observation, R8 was transferred to a wheelchair with these restraints in place, and staff members indicated that the restraints were used to prevent R8 from falling, as R8 had previously fallen and sustained injuries. Despite this, the Director of Nursing and the Administrator did not consider these devices as restraints, even though they were coded as such in the Minimum Data Set (MDS). The facility's failure to properly assess and document the use of these restraints, as well as to update the care plan accordingly, led to the deficiency identified by the surveyors.
Failure to Maintain Personal and Oral Hygiene for a Resident
Penalty
Summary
The facility failed to consistently maintain good personal and oral hygiene for a resident diagnosed with Epileptic Syndrome with Seizures and Mild Neurocognitive Disorder. The resident, who is cognitively intact but totally dependent on staff for oral care, bathing, and dressing, reported that staff never offered to assist with brushing teeth, washing the face, applying deodorant, or cleaning the beard. The resident also mentioned that showers were offered at inconvenient times, leading to refusals, and no alternative times were provided. Observations confirmed the resident's hair appeared dirty and greasy, nails were long with dirt underneath, the beard contained food debris, and clothing was stained. The Director of Nursing confirmed that the resident sometimes refuses showers but should be receiving them at least once per week according to preference. It was also confirmed that the resident needs new, unstained clothing and that staff should be offering assistance with morning care, including face washing, brushing of teeth, combing hair, and cleaning hands and nails. The facility's A.M. Care policy requires nursing assistants to provide daily care, including oral hygiene, washing, and dressing in clean clothing, which was not consistently followed for this resident.
Infection Control Lapse in Catheter Care
Penalty
Summary
The facility failed to maintain infection control standards during catheter irrigation for a resident with multiple diagnoses, including Spastic Quadriplegic Cerebral Palsy and a history of urinary tract infections. The Medication Administration Record for the resident indicated an order to flush the indwelling catheter twice daily with normal saline. During an observation, a Licensed Practical Nurse (LPN) did not wash their hands before performing the catheter irrigation. Additionally, the LPN disconnected the catheter from the drainage tubing without cleansing the connection site with antiseptic wipes, as required by the facility's protocol. The LPN acknowledged the oversight when questioned about the procedure. The facility's policy on the irrigation of indwelling catheters, last reviewed in March 2018, mandates handwashing and cleansing of the connection site with antiseptic wipes before reconnecting the tubing to the catheter using aseptic technique. The failure to adhere to these infection control practices was observed during the procedure, contributing to the deficiency noted in the report.
Failure to Maintain Sanitary Conditions for Respiratory Care Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions for respiratory care equipment for two residents. One resident, diagnosed with Congestive Heart Failure and Atrial Fibrillation, had oxygen tubing lying on the ground, with an undated nasal cannula attached to a concentrator running at two liters per minute. The humidifier bottle was empty, undated, and had white dried residue at the bottom. Another resident, diagnosed with Chronic Obstructive Pulmonary Disease, had oxygen tubing hanging over the concentrator with the nasal cannula touching the floor. The Director of Nurses confirmed that staff should store oxygen tubing in plastic bags, refill humidifier bottles as needed, and change tubing and humidifier bottles weekly, dating and documenting these changes in the Treatment Administration Record.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD) as a result of decades of spousal abuse. The facility's Trauma Informed Care Policy requires that residents who are trauma survivors receive care that accounts for their experiences and preferences to prevent re-traumatization. However, the resident's care plan did not include interventions related to their PTSD, despite the interdisciplinary team being aware of the diagnosis. Observations revealed that the resident appeared anxious and expressed uncertainty about their actions, yet no staff intervened to assist or redirect them. Interviews with the Social Service Director and the Director of Nursing confirmed that the resident's PTSD diagnosis was known, and a care plan should have been in place to address identified triggers. The lack of a trauma-informed care plan for the resident represents a deficiency in the facility's compliance with its own policy and professional standards of practice.
Failure to Maintain Secure Bed Rail for Resident with Behavioral Disturbances
Penalty
Summary
The facility failed to maintain a safe and secure bed rail for a resident diagnosed with a history of falling, mixed Alzheimer's vascular dementia with behavioral disturbances, insomnia, anxiety, psychotic disorder, bipolar disorder with psychotic features, attention concentration deficit, and chronic obstructive pulmonary disease. The resident was prescribed the use of a right 1/2 side transfer bar for bed mobility. During an observation, the resident's side rail was found to be extremely loose, moving from side to side and front to back, creating a significant gap between the bed mattress and the side rail. The Maintenance Director acknowledged the looseness of the bed rail and noted that the resident's behaviors, including aggression and shaking the bed rail, increased the risk of falls. The Maintenance Director also stated that bed rails are not routinely checked unless they are new or the resident changes rooms or beds, and expected staff to notify him if a bed rail needed fixing. The Administrator confirmed the need for frequent checks of the resident's bed rail due to her cognitive and behavioral issues and fall risk.
Failure to Dispose of Medication for Deceased Resident
Penalty
Summary
The facility failed to properly dispose of a medication for one resident reviewed for medication administration. According to the facility's Drug Release/Destruction Policy, discontinued medications or those belonging to discharged residents should be destroyed as soon as practical and within seven days of discharge or drug discontinuation. During an inspection of the medication room, a zip lock package of Bisacodyl Suppositories labeled with the resident's name was found in the medication refrigerator. The Director of Nursing confirmed that the resident had expired and acknowledged that the medication should have been disposed of according to the facility's policy.
Medication Administration Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12% error rate. This was due to three medication errors out of 25 opportunities, affecting one resident. The facility's Medication Administration policy requires medications to be administered within one hour of the designated time. However, on December 16, 2024, a registered nurse administered seven medications to a resident at 9:20 AM, which included Tramadol, Tylenol, and Gabapentin, not within the one-hour window of the scheduled 8:00 AM time. The Director of Nursing confirmed the acceptable administration window is one hour before and after the ordered time.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
The facility failed to provide necessary dental services for a resident diagnosed with Epileptic Syndrome with Seizures and Mild Neurocognitive Disorder. The resident's Physician Order Sheet indicated a need for dental services as required, yet the Care Plan Summary did not address this need or the resident's broken teeth. The resident, who is cognitively intact, reported that staff never offered assistance with dental hygiene and that he had not seen a dentist since admission, despite having multiple broken teeth affecting his diet. Observations confirmed the resident's teeth and gums were coated with debris and had broken teeth. The Director of Nursing acknowledged the lack of regular dental services in the facility and confirmed the resident's need for dental care. The Administrator also confirmed the absence of contracted dental services for routine check-ups and treatment of dental issues.
Failure to Arrange Dental Services for Resident with Broken Dentures
Penalty
Summary
The facility failed to provide or assist in arranging dental services for a resident, identified as R24, who had broken dentures. R24's care plan, dated April 19, 2024, indicated the need for oral and dental health maintenance due to being edentulous, with instructions to coordinate dental care and transportation as needed. Despite these instructions, R24's family member, V20, reported on December 15, 2024, that R24 had not received new dentures after the previous set was broken at another nursing home. V20 had repeatedly requested dental services for R24, including speaking to the facility's administrator, but the facility only provided ground food, which R24 disliked. On December 16, 2024, the Director of Nursing, V2, acknowledged that arrangements for dental care should have been made by that time, as R24 had been at the facility for several years. V2 also denied knowledge of any existing arrangements with a dental service to provide care for residents at the facility.
Lack of Communication and Documentation in Hospice Care
Penalty
Summary
The facility failed to establish an effective communication process with the hospice service provider, resulting in the absence of an up-to-date Hospice Plan of Care for a resident diagnosed with Generalized Anxiety Disorder, Dementia, and Alzheimer's Disease. The resident's medical record lacked the necessary Hospice Plan of Care, and the communication binder used by the hospice service provider did not contain any nursing entries by the hospice RN for this resident. This indicates a breakdown in the communication and documentation process between the facility and the hospice service provider. The Resident Care Coordinator acknowledged that the hospice RN's method of communicating changes in orders or care was inadequate, as it involved merely repositioning the page in the resident's chart without notifying the nursing staff or documenting in the communication binder. The facility's agreement with the hospice provider required the designation of an interdisciplinary group member responsible for coordinating hospice care and communicating with facility representatives. However, this coordination and communication were not effectively implemented, leading to the deficiency.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to make the survey results readily accessible to residents, potentially affecting all 44 residents residing in the facility. During a resident council meeting, residents expressed that they were unaware of the location of the State inspection book. Upon inquiry, the Administrator indicated the survey book was located in a room off the front door, placed on the top shelf of a bookshelf, not at wheelchair eye level, and surrounded by many other books, making it not easily visible or accessible. This placement does not comply with the Illinois Department on Aging Residents' Rights, which states that residents have the right to see reports of all facility reviews from the most recent to the last three years.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a qualified director of food and nutrition services, affecting all 44 residents residing in the facility. This deficiency was identified through observation, interview, and record review. On December 15, 2024, the Administrator acknowledged that the facility had been without a qualified Dietary Manager since the previous one quit. A new Dietary Manager was hired and began work on December 16, 2024, but was still in the process of being trained and qualified. On the same day, the new Dietary Manager was observed actively supervising and directing the meal service for lunch. The facility's application for Medicare and Medicaid confirmed the presence of 44 residents at the time of the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 135 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Farmer City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Piatt County Nursing Home | 15.2 mi | ★★★★★ | 0 | 0 |
| Goldwater Care Clinton | 18.4 mi | ★★★★★ | 56 | 0 |
| Goldwater Care Gibson City | 20.8 mi | ★★★★★ | 12 | 0 |
| Haven Of Champaign | 21.6 mi | ★★★★★ | 14 | 0 |
| Gibson Community Hsp Annex | 21.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.