Inspection·April 25, 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 follow proper infection control techniques during wound care for 1 of 5 residents (R30) reviewed for infection control in the sample of 30. Residents Affected - Few The findings include: R30's face sheet documents an admission date of 12/15/23 with diagnoses including: Sepsis, unspecified, Unspecified open wound, left foot, Laceration without foreign body of left lesser toe(s) without damage to nail, Other iron deficiency anemias, Type 2 diabetes mellitus with unspecified complications, Venous insufficiency (chronic) (peripheral), Muscle wasting and atrophy, not elsewhere classified, multiple sites, Unspecified open wound of unspecified toe(s) without damage to nail, sequela, Pain, unspecified, Other hypoglycemia, Unspecified atrial fibrillation, Muscle weakness (generalized), Other abnormalities of gait and mobility, and Other lack of coordination. R30's Minimum Data Set (MDS) dated [DATE] documents under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates that R30 is cognitively intact. Section GG documents R30 is dependent with toileting, showering, and dressing. R30's Current Care Plan documents under problems: R30 has a diabetic ulcer to left heel with intervention of: enhanced barrier precautions per facility protocol and treat ulcer as ordered. R30's Care Plan documents that R30 is at risk for skin breakdown or pressure ulcers related to decreased mobility with interventions of: keep skin clean and dry as possible and observe skin condition with daily care. R30's Care Plan documents that R30 is at risk for complications due to diabetes diagnosis with intervention of: notify V13 (Medical Doctor) as needed. R30's Physician orders documents an order dated 03/06/24 for Betadine 10% solution to open wound, to left foot, cleanse wound with normal saline (NS) apply betadine and calcium alginate and gauze wrap every day. On 04/24/24 at 1:38 PM, V4 (Registered Nurse) was observed donning a gown and gloves and entering R30's room, which had a sign on the door that stated enhanced barrier precautions. V4 placed a clean towel on a bedside table and placed treatment supplies with several pairs of gloves on the towel. V4 removed a pair of scissors from her pocket. V4 cut the soiled dressing off R30's foot with the scissors, the contaminated scissors were placed on the clean towel next to the clean dressing supplies without cleansing the scissors. V4 doffed her soiled gloves and donned clean gloves without performing hand hygiene between. V4 used the soiled scissors and cut a clean piece of gauze from a roll. V4 took the piece of gauze and some normal saline and cleansed R30's foot. V4 doffed her gloves and donned a new pair of gloves without performing hand hygiene. V4 applied betadine to R30's left heel (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: 146088 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 146088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Benton 1310 Mark Franklin Louis Street Benton, IL 62812 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)