Graham Hospital

Based on interview and record review the facility failed to ensure residents' comprehensive care plans were individualized to reflect each resident's specific needs, conditions, and preferences. This failure affects all 21 residents who reside at the facility. Findings include: The facility's Care Plan Policy revised 3/10/25 documents the individualized care plan is used to outline the care in which the patients shall receive during their stay. A plan of care which defines patient or family outcomes within a pre-established time frame, prompting continuity of care using interventions to meet expected outcomes. The documented plan of care is based on the patient's goals and time frames, settings, and services required to meet those goals. Goals need to be realistic, individualized, patient centered, measurable, dated, the care plan needs to be reviewed daily to determine if goals are being met. The facility's Patient/Resident Care Plan and Care Conference revised September 2025 documents Patients/residents shall have an individualized care plan. The resident care plan helps to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure sanitary conditions were maintained during food preparation and service to prevent cross-contamination and foodborne illness, in accordance with professional standards for food safety. This failure has the potential to affect all 21 residents who reside at the facility.Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/30/26 and signed by V1 (Administrator) documents 21 residents reside within the facility.On 03/30/2026 at 11:05 AM, V8 (Cook) was observed cleaning main food preparation areas with a wash rag while food on the steam table remained uncovered. The same wash rag was placed on the counter and subsequently used to clean a food thermometer between temperature checks of the food on the steam table. During continued observation, V8 was observed wiping sauce from the lasagna with her fingers onto the same wash rag used to clean the counters and thermometer. When checking hamburger temperatures, the initial holding temperature was 142 F, V8 stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Facility failures resulted in two deficient practices.A. Based on interview and record review, the facility failed to establish and maintain an effective infection prevention and control program by failing to perform surveillance to track and monitor residents and staff illnesses and differentiating between resident facility-acquired and community acquired infections. This failure has the potential to affect all 21 residents residing in the facility.B. Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions while providing incontinent cares for one of 12 residents reviewed for infection control practices in the sample of 21.Findings include:A. The facility's Infection and Prevention Control Program Plan, dated March 2024, documents Policy: Based on current scientific knowledge, accepted practice guidelines, and applicable law and regulations, the hospital shall provide written policies and procedures related to Infection Control, surveillance and prevention for all departments of the organization. To assist in the prevention…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist completed specialized Infection Prevention and Control (IPC) training prior to performing the role. This failure has the potential to affect all 21 residents residing in the facility. Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/30/26 and signed by V1 (Administrator) documents 21 residents reside within the facility.The facility's Infection and Prevention Control Program Plan, dated March 2024, documents Policy: Based on current scientific knowledge, accepted practice guidelines, and applicable law and regulations, The hospital shall provide written policies and procedures related to Infection Control, surveillance and prevention for all departments of the organization. To assist in the prevention of the transmission of infections the entire staff is responsible for adhering to policies and procedures related to infection control. 7. Infection Control Professional: a. A Registered Nurse with knowledge of epidemiology…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter bag was covered to maintain the resident's dignity for one of one resident (R19) reviewed for dignity in a sample of 21.Findings include:The Illinois Long-Term Care Ombudsman Program Resident Rights Booklet, dated 11/18, documents Your rights to dignity and respect: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.R19's MDS (Minimum Data Set) Assessment, dated 3/26/26, documents R19 is severely cognitively impaired and has an indwelling catheter. R19's Physician Orders, dated 3/13/26, indicates R19 has an indwelling urinary catheter. On 3/30/26 at 10:27 AM R19 was sitting in her recliner in her room with the door open. R19's urinary catheter drainage bag was observed hanging on the side of R19's bed (facing the door) and was not covered by a dignity bag. The drainage bag was one fourth full of yellow urine. On 3/31/26 at 11:42 AM V1 (Administrator) stated R19's urinary catheter bag should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accurately code the MDS (Minimum Data Set) Assessments for two of two residents (R5 and R8) reviewed for MDS Accuracy in the sample of 21. Findings Include: CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual Section P: Restraints and Alarms dated 10/2025 documents, 'Intent: The intent of this section is to record the frequency that the resident was restrained by any of the listed devices or an alarm was used, at any time day or night, during the seven-day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories. 1.R8's current Physician's Order dated 3/16/26 documents R8 utilizes bilateral upper side rails for positioning and bed mobility. R8's MDS assessment dated [DATE] documents R8 is cognitively intact and uses bedrails as a restraint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a restorative range of motion program for one of one resident (R6) reviewed for limitations in range of motion in the sample of 21.Findings include:The facility's Restorative Range of Motion Policy dated 2/2026 documents, The restorative Range of Motion program shall provide the patient with the assistance required to maintain and improve joint mobility and promote a greater sense of well-being, thus assisting in the prevention of contractures, pain, and edema. Objectives: 1.To maintain and improve range of motion to an extremity that has decreased ability and movement. 2. To prevent a decrease in patient mobility due to loss of ROM (Range of Motion). 3. To increase joint flexibility, thus leading to greater ease of ADLS (Activities of Daily Living) and transfers. A physician's order shall not be required for initial assessment of the Restorative Nurse Assistant program but shall be required for establishing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to assess and identify entrapment risk associated with the use of side rails and document alternatives to side rails with outcomes prior to installing side rails for one of two residents (R5) reviewed for side rail use in a sample of 21.Findings include:The facility's Side Rails and Entrapment Policy, dated February 2026, documents, Policy: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach shall be used to achieve sustainable quality outcomes, including 1) regular bed maintenance and 2) individual bed rail evaluations. In response to the requirement of providing for a safe, clean, comfortable, and homelike environment, the facility's regular preventative maintenance program shall include regular inspection of all bed systems (rails, frames and mattresses, and operation components) to ensure they are clean, comfortable, and safe. The facility shall also ensure individual resident bed rail evaluations are performed on a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to use temperature testing strips to ensure dishes reach the required surface temperature during the rinse cycle in the dish machine, failed to ensure hanging light covers over the kitchen's fryer baskets were clean and free of debris and grime, and failed to complete and record cool down temperatures for prepared meats and leftover items that were prepared ahead and stored in the facility's refrigerator and freezer for future use. These failures have the potential to affect all 22 residents residing in the facility. Findings include: 1.) The facility's Washing and Storage of Dishes and Utensils policy, dated 4/2024, documents The dish machine water temperatures are as follows: Wash cycle: 150 to 165 degrees. Rinse cycle: 160 to 180 degrees. Final Rinse cycle: 180 to 195 degrees. If the proper temperatures are not met, the management team is notified. On 12/16/24 at 10:20 AM V5 (Dietary Manager) ran a temperature test cycle on the facility's dish machine. V5 stated the facility's dishwasher is a high temperature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement restorative programming for five of six residents (R5, R9, R11, R13, and R15) reviewed for limitations in range of motion in the sample of 21. Findings include: The facility's Restorative Activity Aide Job Description (undated) documents, The restorative aide will perform specialized restorative nursing and activities of daily living activities for residents, assess and documents the resident's response and assist the nursing staff as directed. Primary Duties and Responsibilities: 1. Is responsible to perform specific restorative nursing procedures. (Example: Exercises, ambulation, and assistance with ADLs (Activities of Daily Living), to residents as directed by the MDS (Minimum Data Set) Coordinator. 2. Is responsible to keep daily performance records on residents receiving restorative nursing procedures. Reporting to MDS Coordinator daily refused treatments, omitted treatments, or other adverse observations. 3. Is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to refer a resident to the PASRR (Preadmission Screening and Resident Review) State Agency to obtain a Level II PASRR after experiencing a significant change in behavioral and psychiatric symptoms for one of one resident (R2) reviewed for Mental Illness in the sample of 21. Findings include: The facility's (PASSR) policy dated 9-5-24 documents, It is the responsibility of the Psychosocial Designee and/or designated staff to coordinate and ensure compliance with all PASRR federal, state, and local mandates including working with Illinois Maximus PASRR designated agency. The Psychosocial Designee or designated staff shall refer to the designated state agency any resident whose behavioral health condition had declined or worsened and is significantly changes from the most recent PASRR Level II evaluation. Residents with documented mental health condition and/or suspected of mental health conditions shall be referred to the state agency for determination of a mental health condition. This includes but is not limited to residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform COVID-19 testing on staff with direct high-risk exposure to a COVID-19 positive resident. The facility also failed to implement their COVID-19 Response Plan to monitor residents at least daily for a fever to prevent the potential spread of COVID-19 virus. These failures had the potential to affect the 15 residents residing on the facility ICF (Intermediate Care Facility East wing). Findings include: The CDC's (Centers for Disease Control) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 5/8/23, documents, Nursing homes: Responding to a newly identified SARS-CoV-2-infected HCP or resident: When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP (Healthcare Professional) or resident should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.