Inspection·October 18, 2024

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** Based on observation, interview, and record review, the facility failed to maintain aseptic technique while performing a dressing change during wound treatment for 1 (R21) of 2 residents reviewed for infection control in the sample of 23. Residents Affected - Few Findings include: R21's Face Sheet documented an admission to the facility on 2/2/24 and listed diagnoses including type 2 diabetes mellitus without complications, pressure ulcer of left heel stage 2, unspecified diastolic (congestive) heart failure and unspecified intellectual disabilities. R21's Physician Order Summary documented an order dated 10/11/2024, metronidazole 500mg. Cleanse area to left heel with NS (normal saline) or wound cleanser and apply betadine, crushed flagyl, calcium alginate and kerlix daily and as needed. R21's Minimum Data Set (MDS) dated [DATE] documents no Brief Interview for Mental Status (BIMS) score. Section C0700, under staff assessment for mental status documented memory problem, showing R21 had severe cognitive impairment. On 10/16/2024 at 2:50 PM, V4 (Licensed Practical Nurse/LPN) and V3 (Assistant Director of Nursing/ADON) provided dressing change to left heel for R21. V4 and V3 gathered supplies that included wound cleanser spray, betadine, metronidazole, calcium alginate, kerlix and tape. There were no extra gloves set up for care. V4 donned a gown, washed her hands with soap and water, then donned gloves prior to procedure. During observation of R21's dressing change, V4 removed the old dressing dated 10/15/2024. Once the old dressing had been removed, V4 started to clean the wound with the wound cleanser spray and applied betanidine 10% to the wound area with a cotton ball, without donning new gloves or washing her hands. V4 then applied crushed metronidazole 500 mg tablet with calcium alginate to the wound. V4 finished the dressing change by wrapping the calcium alginate with kerlix wrap and secured it in place with tape. No observation of hand hygiene or new gloves donned throughout the entire wound dressing change procedure. On 10/16/2024 at 3:02 PM, V4 (LPN) stated she did not change her gloves during R21's dressing change. V4 did confirm that she should have donned new gloves and washed her hands between removing the old dressing and cleaning the area per the facility policy and procedure. On 10/16/2024 at 3:03 PM V3 (ADON) stated, V4 did not change her gloves during R21's dressing change per the facility's policy and procedure. V3 stated, V4 should have changed her gloves. (continued on next page) 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 2 Event ID: 145628 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 145628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Nursing & Rehab Center 1115 North Wenthe 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)