Health inspection·May 10, 2024

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 perform hand hygiene during resident cares for two of 12 residents (R36 and R40) reviewed for infection control in a sample of 18. Residents Affected - Few Findings include: 1) R36's current Care Plan, documents that R36 has an indwelling urinary catheter and that R36 requires staff assistance with all cares. On 05/08/24 at 8:30 am, R36 was sitting on the commode in R36's bathroom and V4 (Certified Nursing Assistant/CNA) was performing indwelling urinary catheter care. While wearing the same soiled gloves V4 (CNA) then completed the following tasks: set up two wash basins to cleanse R36 of stool; emptied R36's indwelling urinary catheter drainage bag (leg bag) of urine into the commode; washed and wiped bowel/stool off R36's buttocks; pulled up R36's pants; and assisted R36 to the wheelchair. V4 then removed V4's soiled gloves. V4 did not perform hand hygiene or change gloves during R36's cares. On 05/08/24 08:35 am, V4 (Certified Nursing Assistant/CNA) stated, I should have changed gloves after I did catheter care and before cleaning bowel from (R36's) rectum. On 5/8/24 at, V2 (Director of Nursing) stated, The Nurses and CNA's (Certified Nursing Assistant's) should be performing hand hygiene during all cares, especially when they go from a contaminated area to clean. Facility Catheter Care, Urinary Policy, undated, documents: the purpose of this procedure is to prevent catheter-associated urinary tract infections; place equipment on the bedside stand; wash and dry hands thoroughly or use antimicrobial hand gel; put on gloves, thoroughly rinse perineal area including the penis/scrotum; thoroughly rinse perineal area in same order, using fresh and clean washcloth; gently dry perineum; rinse washcloth or use a clean one and apply soap or skin cleansing agent; wash and rinse the rectal area thoroughly, including under the scrotum, anus and buttocks and dry; discard any disposable items into the designated containers; remove gloves and discard into designated container; wash and dry hands thoroughly or use antimicrobial hand gel; reposition and make resident comfortable; clean the bedside stand if used; and wash and dry your hands thoroughly. 2) On 5/8/2024, at 10:05 a.m., V6/Certified Nursing Assistant, during indwelling catheter care donned gloves. V6 then without changing gloves, proceeded to transfer R40, using a sit to stand lift, to R40's bed. V6 pulled down R40's pants and incontinence brief. V6 then adjusted the empty trash bag on R40's bed; grabbed a clean, wet, soapy, wash rag and wiped R40's catheter tubing. V6 placed the dirty rag in a plastic trash bag on R40's bed; grabbed a clean, wet, soapy, wash rag and wiped R40's genital area. V6 placed the dirty rag in the plastic trash bag on R40's bed. V6 grabbed the clean wet rag and rinsed R40's catheter tubing and R40's genital. V6 placed rag in the trash bag; grabbed a dry towel and dried R40's genital and catheter tubing. V6 placed the towel in the trash bag; adjusted R40's catheter tubing; pulled up R40's incontinence brief and pants. On 5/8/24, at 10:10 am., V6 confirmed V6 should have, but did not, change gloves during catheter care when going from dirty to clean. On 5/8/24, V2/Director of Nursing confirmed the expectation that V6 should have changed gloves, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146103 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 146103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henderson County Ret Center 604 Oakwood Drive Stronghurst, IL 61480 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 during catheter care when going from dirty to clean. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146103 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 146103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henderson County Ret Center 604 Oakwood Drive Stronghurst, IL 61480 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to follow an Antibiotic Stewardship program. This failure has the potential to affect all 41 residents who currently reside in the facility. Residents Affected - Many Findings Include: CMS form 671 signed by V1, Administrator, on 05/08/24 documents there are 41 residents living in the facility. On 5/8/24 at 10:30 AM V3 (Licensed Practical Nurse/Infection Preventionist) stated that the facility utilizes the McGreer Criteria which are written definitions of what constitutes an infection. The Facility's Infection Control Monitoring Logs for January, February, March, and April 2024 listed all of the residents who had been on antibiotics for infections, there was no documentation of monitoring of signs and symptoms of infections prior to antibiotic use, or any documentation of any evidence-based criteria used to define any of the infections prior to antibiotic use. On 5/8/24 at 10:40 AM V6 (Registered Nurse/ Assisted Director of Nursing) stated We need to train our nurses on McGreer Criteria for identifying what is an infection and what does not meet the criteria. The Facility's Antibiotic Stewardship policy dated 4/7/2020 documents The facility will develop an Antibiotic Stewardship Program that promotes appropriate use of antibiotics for quality of care, successful resident outcomes and reduction of potential adverse consequences related to antibiotic use. A collaborative effort between the resident/resident representative, interdisciplinary team, practitioners, Medical Director, pharmacist and leadership team is essential for success of the Antibiotic Stewardship Program. The Facility's Antibiotic Stewardship policy also documents when the nurse suspects that the resident has an infection, the nurse will perform an evaluation of the resident that includes Resident signs and symptoms, assessment/vital signs, interview the resident for symptoms. The Nurse will document all assessment findings in the electronic medical record. The Facility's Antibiotic Stewardship policy also documents The Infection Preventionist will track antibiotic use and monitor adherence to evidence-based criteria, including documentation related to antibiotic selection and use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146103 If continuation sheet Page 4 of 4