Health inspection·August 1, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few high contact resident care activities. 2. Enhanced barrier precautions apply when: a. A resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained, b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained, and c. Contact precautions do not otherwise apply. 3. Contact precautions apply when: a. A resident is infected or colonized with any MDRO and has secretions or excretions that cannot be covered or contained, and b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and has secretions or excretions that cannot be covered or contained, or c. A resident is infected or colonized with any MDRO and there is a current investigation of a suspected or confirmed MDRO outbreak. 4. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. 5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. Peripheral IV catheters are not considered an indwelling medical device for purposes of EBPs. 6. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen. 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact 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. c. Face protection may be used if there is also a risk of splash or spray. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care); i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and j. wound care (any skin opening requiring a dressing). The facilities Performance Skill #5.2 Providing Catheter Care, not dated, documents, Cleans tubing of catheter nearest meatus. Moves in only one direction, away from meatus. Uses a clean area of cloth for each stroke. R40's admission Record documents R40's date of admission to the facility was 4/4/11 and his diagnoses include Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting right non-dominant side, Vascular Dementia Moderate with other Behavioral Disturbance, Urinary Tract Infection, Retention of Urine. R40's Minimum Data Set (MDS) assessment dated [DATE], documents that R40 has an indwelling urinary catheter. R40's Physician orders dated 6/14/24, documents that R40 has an order for 18 FR (French) with 10 cc (cubic centimeter) indwelling urinary catheter for Neuromuscular Dysfunction of Bladder related to Hemiplegia and Hemiparesis following Cerebrovascular Disease. R40's current care plan documents R40 is on Enhanced Barrier Precautions for Indwelling catheter and documents R40 has an Indwelling Catheter for Neuromuscular Dysfunction of Bladder, Hemiplegia following CVA (Cerebrovascular Accident). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145697 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 145697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 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 0690 On 7/30/25 at 8:41 AM, R40 stated he has had a catheter for a while because he cannot urinate. Level of Harm - Minimal harm or potential for actual harm On 7/30/2025 at 9:03 AM, V5 (Certified Nursing Assistant/CNA) observed providing indwelling urinary catheter care on R40. V5 (CNA) did not wear a gown during cares and did not cleanse down the urinary catheter. V5 (CNA) stated, I know what I did wrong, I should have worn a gown during his (R40) catheter care and you are right I did not wash down the catheter tubing. Residents Affected - Few On 7/30/2025 at 12:00 PM V2 (Director of Nursing/DON) stated, I expect my staff to follow policy on catheter care by knocking on the door, telling the resident what they are going to do and put the appropriate PPE (Personal Protective Equipment) on prior to doing the care. V2 (DON) also stated, I have never seen a catheter care policy that states to cleanse the catheter tubing. On 7/31/2025 at 8:20 AM, V22 (Infection Preventionist) stated, If a resident has an indwelling urinary catheter, they should be wearing a gown and gloves with all cares except feeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145697 If continuation sheet Page 3 of 3