Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, and interview, the facility failed to provide a homelike environment when an
alarm was placed on a restroom door affecting two (R29, R69) of 18 residents reviewed for homelike
environment in a sample of 31.
Findings include:
Facility policy, dated 01/30/24, and titled Safe and homelike environment documents, The facility will
provide a safe, Clean, comfortable and homelike environment. Definition for comfortable sound levels
means levels that do not interfere with the resident's hearing, levels that enhance privacy when privacy is
desired, and levels that encourage interaction when social participation is desired.
On 04/22/24 at 9:48 AM, the bathroom door of R29 and R69's was noted to have a tab alarm active. R69
had a chair alarm and an alarmed mat on the floor next to her bed. R69's Minimum Data Sheet (MDS),
dated [DATE], documents R69 has a Brief Interview for Mental Status score of 7 indicating severe cognitive
impairment. R29's 03/15/24 MDS R29 has severe cognitive impairment.
On 04/22/24 at 9:48 AM, a tabbed alarm was noted to be attached to the frame of R29's and R69's
bathroom door with the tab mounted to the door.
On 04/23/24 at 12:59 PM, V5, Care Plan Coordinator, stated the tabbed alarm on the bathroom door was
intended to keep R69 from attempting to go into the bathroom independently and potentially falling.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145596
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
145596
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Snyder Village
1200 East Partridge
Metamora, IL 61548
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
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
2. On 04/22/24 at 10:02 AM, V5, Infection Preventionist, was observed changing R45's sacral area wound.
V5 was assisted by V4 who was wearing gloves. V5 washed her hands, donned gloves and cleaned R45's
wound with cleanser. V5 then removed her gloves and washed her hands again before donning new gloves,
packing R45's wound with calcium alginate and applying a border gauze.
Residents Affected - Many
V4 and V17, both CNAs, then utilized a mechanical lift to transfer R45 to the recliner. During the transfer, V4
and V17 wore only gloves. Both CNAs verified they only wear gloves for R45, and did not know they needed
to wear anything else. V4 and V17 both verified they help out on any hallway that needs help to make sure
the residents are taken care of.
No gowns or signage indicating R45 required enhanced barrier precautions due to wounds was seen in
R45's room.
On 04/22/24 at 10:12 AM, V4, Assistant Director of Nursing/Infection Preventionist, was observed
administrating R17's Vancomycin through a peripherally inserted central catheter (PICC) line in R71's left
arm. V4 donned gloves, identified R71, then cleaned and flushed the PICC line with Normal Saline prior to
connecting the Vancomycin. At that same time, V4 verified she only wears gloves with R17's IV.
V4 did not wear a gown and there was no signage for Enhanced Barrier Precautions in R71's room.
The Centers for Medicare and Medicaid Services form 671 entitled Long Term Care Facility for Medicare
and Medicaid, dated 4/21/2024, and signed by V1/Administrator documents 76 residents currently residents
in the facility.
Based on interview, record review, and observation, the facility failed to implement Contact Isolation
Precautions and Enhanced Barrier Precautions to contain the potential spread of Multi Drug-Resistant
Organisms. This failure has the potential to affect all 76 residents residing in the facility.
Findings Include:
Current facility map documents their are four hallways in the nursing home.
The facility policy named, Enhanced Barrier Precautions/EBP, dated 3/20/24, documents, It is the policy of
this facility to implement Enhanced Barrier Precautions for the prevention of transmission of
Multidrug-Resistant Organisms. Enhanced Barrier Precautions refer to an infection control intervention
designed to reduce transmission of Multidrug-resistant organisms that employs targeted gown and gloves
use during high contact resident activities, such as dressing, bathing, providing hygiene, wound care: any
skin opening requiring a dressing.
The facility policy named, Transmission-Based (isolation) Precautions, dated 1/30/2024, documents, It is
our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens
mode of transmission.
1. R334 did not have any signage on the door to show R334 was in isolation or EBP precautions.
R334's Wound Round-description, dated 4/23/2024, documents, Site one: Infection, back 2.7 x 6 x
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145596
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
145596
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Snyder Village
1200 East Partridge
Metamora, IL 61548
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
0.4CM (Centimeters). Negative Pressure Wound Therapy twice a week.
Level of Harm - Minimal harm
or potential for actual harm
R334's wound culture results of R334's back, from a local hospital, dated 3/26/2024, documents, Heavy
Methicillin Resistant Staph Aureus.
Residents Affected - Many
R334's Care plan, dated 4/10/2024, documents, (R334) requires intravenous antibiotic therapy due to
MRSA (Methicillin- resistant Staphylococcus aureus) resulting from an infection in the wound on his back.
R334's Wound Evaluation and Management Summary, dated 4/23/2024, documents, Wound Back Full
Thickness, etiology: infection, duration over 21 days. Primary Dressing: Negative pressure wound therapy.
Apply twice a week and as needed for 16 days. Site one: Surgical Excisional Debridement Procedure:
Remove Necrotic Tissue and Establish the Margin of Viable Tissue.
On 4/21/2024 at 10AM, R334 was laying in his bed resting, watching television. R334's wound vacuum to
his back and tubing is laying in the bed. R334 stated, This is used for the infection I have in my back. R334
did not have any signage on the door to show R334 was on isolation precautions.
On 4/23/2024 at 12:30PM, V2/DON (Director of Nurses) stated, (R334) is not on any isolation right now.
(R334) has a wound vac that is in place all the time. The infection that (R334) has is always contained. We
did not place him on Enhanced Barrier Precautions or Contact Isolation.
On 4/23/2024 at 12:45PM, V3/Infection Preventionist stated, No, we did not put (R334) on Contact isolation
or Enhanced Barrier Precautions. (R334) has a wound vac in place so, he does not need to be isolated.
On 4/23/2024 at 1:10PM, V12/LPN(Licensed Practical Nurse) stated, R334 is not in isolation. When his
wound vac is changed, we only use gloves, and no gowns are needed.
On 4/24/2024 at 10:30AM, V16/Bath Aide stated, I give every resident in the facility a bath or shower,
except for 200 halls. I go to all halls. (R334) gets a bath from me. He can come down to the shower room
and gets into the bath carefully. The nurse who is on duty will take his wound vac off and leave it off while
he gets his bath. I only use gloves when bathing (R334). The gloves get a lot of water in them when bathing
him, but I still have to use them because his wound is infected.
On 4/23/2024 at 1:20PM, V13/CNA(Certified Nursing Assistant) stated, When I take care of (R334) I only
use gloves. I do not use a gown when taking care of (R334). At that same time, V13 verified she helps out
on any hallway that needs help to make sure the residents are taken care of.
On 4/23/2024 at 1:30PM, V14/CNA (Certified Nursing Assistant) stated, The only thing I use is gloves
during (R334) cares. He is not on any isolation that I know of. At that same time ,V14 verified she helps out
on any hallway that needs help to make sure the residents are taken care of.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145596
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the April 24, 2024 survey of SNYDER VILLAGE?
This was a inspection survey of SNYDER VILLAGE on April 24, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SNYDER VILLAGE on April 24, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.