Inspection·November 26, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain aseptic technique during bowel incontinence care and catheter care and apply Enhanced Barrier Precautions for 1(R1) of 3 residents reviewed for infection control in the sample of 7. Findings include:R1's admission Record documented an admission date of 9/5/2025 with diagnosis including urinary tract infection, acute kidney failure, unspecified, pressure ulcer of sacral region, unstageable, and malignant neoplasm of endocervix.R1's Minimum Data Set (MDS) dated on 9/11/2025 documented a Brief Interview for Mental Status (BIMS) summary score of 9 which indicates moderate cognitive impairment. This same MDS documents R1 is dependent with care for toileting which required the helper to do all the effort. Section H documented under appliances of an indwelling catheter present and documented R1 is frequently incontinent of bowel.R1's Care Plan documented a focus area of implementation of Enhanced Barrier Precaution due to wound, without secretions or excretions that are unable to be covered or contained in part with an interventions to ensure personnel protective equipment (PPE) and alcohol based hand rub are readily and accessible and use enhanced barrier protection during high contact care activities dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting device care or use central lines, urinary catheter, wound care with an initiation date of 9/8/25. The same Care Plan documents a focus area of Resident may be predisposed to develop skin impairment caused by pressure. R/T (related to) Moderate Risk per Braden Scale- Risk factors noted as: incontinent of bowel. Potential problem for friction and shear contributing factor includes bowel incontinence, limited mobility. Stage 4 pressure wound noted to sacrum with an initiation date of 9/5/25.On 11/24/2025 at 12:29 PM, enhanced barrier precautions signs were observed outside of R1's door with a bin of PPE readily available to be used for contact precautions.On 11/24/2025 at 12:30 PM, V11 (Certified Nurse Assistant/CNA) and V13 (CNA) provided bowel incontinence and indwelling catheter care for R1. V11 and V13 donned gloves. V11 and V13 gathered supplies that included 3 wash cloths and spray foam. V11 and V13 applied gloves then rolled R1 on to her right side. R1 was incontinent of bowel and bowel movement (BM) was observed to R1's sacral area, buttocks, legs and mechanical lift pad. V13 laid all 3 washcloths on R1's mechanical lift pad while wiping BM with one of the washcloths. V13 then folded the washcloth over to wipe again and continued to use the same washcloth for multiple passes not following the front to back method. V13 was observed rolling up the mechanical lift pad under R1 while placing the remaining 2 wash cloths on R1's bed pad. V13 then removed the saturated film covering to the sacral area wound and continued to push the foam back into the wound with her dirty gloves. V13 continued in the same manner of wiping the BM while folding over the washcloths. V13 then passed the dirty washcloth to V11 (CNA) to use. V11 (CNA) sprayed the dirty washcloth with foam spray to clean R1's indwelling catheter tube and perineal area and not following the front to back method. V11 then requested more washcloths. V13 doffed her gloves with no hand hygiene completed and left the room to get more washcloths. V11 returned to R1's room applied new gloves, without completing hand hygiene, and handed the washcloths to V13. V11 had then rolled R1 to her left side and started cleaning BM while using a spray foam cleaner and folding over the washcloths and continuing to use them. Once incontinence care had been completed, V11 and V13 dressed R1 in clean clothes from her closet, covered her with her blankets and set the head of her bed up without changing gloves and without performing and hand hygiene. V11 and V13 doffed their gloves prior to leaving R1's room prior to exiting R1's room without performing hand hygiene. V11 and V13 were not observed wearing a gown while providing catheter and incontinence care to R1.On 11/24/2025 at 12:47 PM, V11 and V13 both stated, the facility does have a policy for perineal care. V11 and V13 stated that they completed perineal care the way they were Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Effingham Healthcare & Senior Living 1610 North Lakewood Drive Effingham, IL 62401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete trained. V13 stated she should have applied the enhanced barrier precautions prior to starting R1's care.On 11/24/2025 at 2:10 PM, V2 (Director of Nursing/DON) stated her expectation for perineal and bowel incontinence care is all staff to follow policy and procedure.On 11/24/2025 at 2:30 PM, V1 (Administrator) stated her expectation is for all staff to follow policy and procedure for perineal and bowel incontinence care.The facility policy titled Perineal Care (revised February 2018) documents Purpose: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. This same document under Equipment and Supplies documented, the following equipment and supplies will be necessary when performing this procedure: 1. Wash basin, 2. Towels, 3. Washcloth, 4. Soap (or other authorized cleaning agent) and 5. Personal protective equipment (e.g. gowns, gloves, mask, etc., as needed). Steps in the Procedure documented 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the wash basin one-half full of warm water. Place the wash basin on the bedside stand within reach.The Centers for Disease Control guidance for Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) updated 4/2/24 found at www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html documents under Enhanced Barrier Precautions The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Event ID: Facility ID: 145514 If continuation sheet Page 3 of 3