Health inspection·August 16, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 08/13/24 at 11:45 am to 12:40 pm, during the lunch hours in the Main Dining Room, meal trays and drinks were being passed. 1. On 08/13/24 at 11:45 am, three residents were eating their meal tray at the same table that R36 was sitting at. R36 did not have a meal tray. At 12:25 pm, R36 was served R36's meal tray and the resident's sitting at R36's table had already consumed their lunch meal. R36 stated that R36 was upset to have to wait as R36 feels they forgot her and R36's table mate's meals, and said that this happens all of the time. They have one staff member passing trays in no particular order with several tables that have residents eating, and others at the table waiting for their food. Event ID: Facility ID: 145697 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 145697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knox County Nursing Home 800 North Market Street Knoxville, IL 61448 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 Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions were implemented and failed to ensure proper disposal of Personal Protective Equipment for four residents (R6, R11, R51, R150) of 28 residents reviewed for Infection Control in a sample of 28. Residents Affected - Some Findings include: Enhanced Barrier Precautions Policy documents, Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBP's) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDRO's) to residents. 2. EBP's employ targeted gown and glove use during high contact resident care activities when precautions do not otherwise apply. A. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). B. Personal protective equipment (PPE) is changed before caring for another resident. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for the EBP's include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing. 5. EBP's are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Personal Protective Equipment Policy documents, Gowns, Aprons, Lab Coats Policy Interpretation, and Implementation, dated 2001, documents, 7. Soiled gowns, aprons, and lab coats must be removed prior to leaving the work area and discarded into the appropriate receptacle located in the work area. 1. R11's Wound Consultation Note, dated 08/14/24, documents R11 has a Stage Four Pressure Wound of the Right Ear full thickness which measures 0.4 x 0.7 x not measurable (centimeters). R11's July 2024 Physician Order Sheet documents an order, dated 08/23/24, to administer J-Tube (Jejunostomy) enteral feedings six times a day for supplement and flush the J-Tube with 210 milliliters of water. On 08/13/24 2:16 pm, V5/Charge Nurse and V6/CNA/Certified Nursing Assistant were observed providing incontinence care to R11. V5 and V6 were not wearing gowns. V5 stated during an interview on 08/13/24 at 2:23 pm, We were in a hurry, we should have worn gowns. On 08/14/24 at 2:48 pm, V7/LPN entered R11's room and donned gloves, but no gown. Medication (Tylenol 325 milligram two tablets) were crushed prior to entering R11's room. V7 then gathered water and spoke with R11 before checking placement and residual of R11's J-Tube. V7 then flushed and administered the medication through R11's J-Tube. V7 did not wear a gown during the administration of R11's J-Tube medications. 2. R150's August 2024 Physician Order Sheet documents a diagnosis of Non-Pressure Chronic Ulcer of unspecified part of Lower Leg. R150's Wound Consultation Sheet, dated 8/14/24, documents R150 has a Non-Pressure Wound of the Right Lower Lateral Leg which is full thickness and measures 2.0 x 0.7 x 0.3 centimeters. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145697 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 145697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knox County Nursing Home 800 North Market Street Knoxville, IL 61448 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 On 08/13/24 at 12:13 pm, V8/LPN entered R150's room and performed glucose monitoring. V8 did not wear a gown. R150 was on a bedpan. V9/CNA and V10/CNA entered R150's room, removed R150's bedpan and used the mechanical lift to assist R150 to R150's electric wheelchair. V9 and V10 did not wear gowns while providing direct care and transferring R150. V8 returned on 8/13/24 at 12:21 pm and administered medication (insulin) to the left lower quadrant of R150's abdomen without wearing a gown. Residents Affected - Some During interview on 08/13/24 at 12:25 pm, V8 does not know why R150 is on Enhanced Barrier Precautions but states that V8, V9 and V10 should have worn gowns. 3. On 8/14/24 at 08:30 am, R6 stated that R6 has an area to the left heel that had originally started as a blister that opened and got infected. R6 is noted to have a bandage showing above the left sock and pressure boot to the left foot. On 08/15/24 at 10:40 am, V3 (Licensed Practical Nurse/LPN) provided wound care to R6 who is in Enhanced Barrier Precautions. V3 (LPN) removed V3's gloves and disposed of them in R6's room. V3 (LPN) then rolled up R6's soiled gown and carried it down the hallway to place it in a linen barrel in the shower room. 4. On 08/15/24 at 10:15 am, V3 (Licensed Practical Nurse/LPN) provided wound care to R51 who is in Enhanced Barrier Precautions for a coccyx wound. V3 walked out of R51's room with V3's gown and gloves on, walked up the hallway to the shower room, and then back to R51's room. V3 then removed and disposed of V3's contaminated gloves, rolled up the contaminated gown, and walked back up the hallway carrying the gown to a barrel in the shower room. On 8/15/24 at 10:30 am, V3 (LPN) stated that V3 should have removed and disposed of V3's gown and gloves in R51's room before exiting. On 08/15/24 11:14 am, V4 (Registered Nurse/ Infection Preventionist) stated that, Staff should have a linen barrel inside of the room to place contaminated gowns in after caring for residents on Enhanced Barriers, and if not available they should place the gown in a plastic trash bag and walk it down to linen barrel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145697 If continuation sheet Page 4 of 4