Health inspection·March 27, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 3/25/25 at 10:15 AM, V4, CNA/Certified Nursing Assistant, provided incontinence care for R45, who was incontinent of stool. V4 did not change gloves after providing incontinence care for R45's bowel movement. At that same time with the same soiled gloves, V4 rolled R45 side to side in bed and placed a clean incontinence brief under R45. With the same soiled gloves, V4 then assisted V6, CNA, with placement of a full mechanical sling under R45 and transferred R45 from his bed into a wheelchair. During R45's transfer, V4 supported R45 and positioned him over the wheelchair while in the sling, and V6 lowered R45 into the wheelchair using the mechanical lift's controls. Residents Affected - Many On 3/25/25 at 10:30 AM, V4, CNA, verified she did not change her gloves or perform hand hygiene throughout R45's incontinence cares and transfer. On 3/26/25 at 1:45 PM, V2, DON/Director of Nursing, stated gloves should be removed, hand hygiene performed, and clean gloves donned after performing incontinence cares and before placing a clean incontinence brief for a resident. The facility was unable to provide a policy identifying appropriate infection control procedures for the donning and doffing of gloves during incontinence care. The facility was also unable to provide a policy and procedure for incontinence care. The facility's Resident Bed List Report, dated 3/25/25, documents 74 residents reside in the facility. Based on observation, interview, and record review, the facility failed to ensure infection control and prevention practices were utilized per policy for three (R13, R45, R55) of 24 residents reviewed in a sample of 24. This failure has the potential to affect all 74 residents who reside in the facility. Findings include: The Transmission-Based (Isolation) Precautions policy, dated 10/24/22, documents, Contact precautions refer to measures that are intended to prevent transmission of infectious agent which are spread by direct or indirect contact with the resident or the resident's environment. High touch objects and environmental surfaces should be cleaned and disinfected with an EPA/Environmental Protection Agency-registered disinfectant for healthcare use at least daily and when visibly soiled. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicate in transmission through environmental contamination (Clostridium-difficile). Residents experiencing fecal incontinence or diarrhea that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, should be placed on contact precautions. The Enhanced barrier Precaution (EBP) policy, dated 3/20/24, documents, EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves during high contact resident care activities. EBP will be initiated for residents with wounds and a physician's order is not required. EBP will be identified by a small sign (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145596 If continuation sheet Page 2 of 4 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 03/27/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many reading EBP placed on the door frame. PPE for EBP is only necessary when performing high-contact care activities. High-contact resident care activities include wound care. The Hand Hygiene policy, dated 1/30/24, documents, The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning and doffing gloves and immediately after removing gloves. The Center for Disease Control (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, documents, To conduct hand hygiene before moving from work on a soiled body site to a clean body site on the same patient and immediately after glove removal. When to change gloves and clean hands: if gloves become soiled with blood or body fluids after a task, if moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs. C-difficile is a spore-forming bacterium that can lead to a common healthcare-associated infection causing severe diarrhea. Spores are inactive form of the germ and have a protective coating allowing them to live on surfaces for months. The CDC's Infection Control Appendix A: Figure. Example of Safe Donning and Removal of Personal Protective Equipment (PPE) documents A gown should gown fully cover torso from neck to knees, arms to end of wrist, and wrap around the back and fasten in back at neck and waist. The facility's Standard Precautions Policy, undated, documents the following: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing care services. 1. R13's Facesheet documents R13 was admitted on [DATE], with diagnoses of Hypertensive Chronic Kidney Disease, Venous Insufficiency, Major Depressive Disorder and Generalized Weakness. On 2/19/25, R13 returned from a hospital stay with diagnoses of Clostridium Difficile (C-diff/Infection of the large intestine), Sepsis (Infection in the blood stream), Pneumonia, Acute Respiratory Failure, and Gastro-Esophageal Reflux Disease with Esophagitis. R13's Stool Culture results, dated 3/21/25, documents R13 tested positive for C-difficile, and antibiotics were ordered. R13's Physician Order, dated 3/13/25, documents to initiate Contact Precautions/Isolation for C-difficile infection. On 3/25/25 at 10:05 AM, R13's door frame had a Contact Precaution sign posted and a sign with instructions to wash hands with soap and water. R13's bathroom had brown substance (stool) on toilet seat, toilet base, and on floor from the doorway to the toilet. The bathroom sink was the only sink available for hand hygiene, and staff would have to walk through the door and past the toilet to get to the sink. On 3/25/25 at 11:00 AM, V5 (Registered Nurse) went into R13's Contact Isolation room and administered medications and cleaned the bathroom. V5's gown was not tied in the back. On 3/25/25 at 10:05 AM, R13 stated she is still having diarrhea stools and had a mess in the bathroom. 2. R55's Face sheet documents R55 was admitted on [DATE], with diagnoses of Closed Fracture Right Femur, Muscle Wasting and Atrophy, Diabetes Mellitus Type 2, Glaucoma, Sacral Wound and Anemia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145596 If continuation sheet Page 3 of 4 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 03/27/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R55's Physician Order, dated 3/6/25, documents to apply collagen sheet into the coccyx wound and cover with calcium alginate and bordered gauze daily. On 3/25/25 at 1:55 PM, V5 (Registered Nurse) was observed to open the treatment cart, remove dressing change supplies and scissors. V5 proceeded to open the collagen package, cut the collagen sheet with scissors from the drawer without cleaning them, then opened the calcium alginate package and walked down the hall to R55's room to conduct wound care on R55. On 3/25/25 at 2:01 PM, R55's doorframe had an EBP sign posted. On 3/25/25 at 2:01 PM, V5, RN, donned a PPE gown and did not button the front of the gown up. At that same time, R55's sacral wound dressing change was conducted. V5 removed R55's dirty dressing and V5 removed gloves and donned new gloves without conducting hand hygiene. On 3/25/25 at 10:50 AM, V2, DON/Director of Nursing, agreed a staff member would have to walk through the brown substance (stool) to get to the sink to wash hands, and could potentially contaminate the environment outside of R13's room. V2 stated, I will get that cleaned up immediately. On 3/27/25 at 11:30 AM, V2, DON, stated, All gowns should have been secured in the back; hand hygiene should have been conducted after gloves were removed; (R13's) bathroom should have been cleaned as soon as possible after being soiled; the wound dressing should have been opened at (R55's) bedside; and scissors should have been disinfected prior to use and prior to placing them back in the treatment cart. On 3/27/25 at 2:20 PM, V1 (Administrator) stated, We like to keep nurses on the same unit because they get to know their residents. It's stable staffing but of course, if someone needs assistance or whatever, the nurses can go anywhere in the facility to care for residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145596 If continuation sheet Page 4 of 4