Health inspection·February 27, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few which indicates R12 is severely impaired. MDS documents, that R12 is a Physical help limited to transfer only, with ADL support provided by staff, with bathing, dressing, toileting, transfers and personal hygiene. R12's progress notes dated 02/21/23 at 9:28PM documents R12 had Diarrhea stool x1 this shift. On 02/22/23 at 11:47AM V8 and V9 performed peri care on R12. V8 entered room and put gloves on. V9 entered room and washed hands and applied gloves. V8 sat R12 on edge of bed and applied gait belt. R12 then stood her up and V9 removed saturated incontinent brief and bed pad. V9 handed saturated linens to V8 and V8 placed linens on floor. V9 then put a clean incontinent bed pad on bed. V8 assisted R12 to lay down on the incontinent bed pad. R12 was laying on her back with her hands on her chest. V8 pulled R12's gown up to R12's chest and laid it on her hands and chest. R12's gown was saturated with urine. V8 then picked up urine saturated linen off the floor and put it in a plastic bag on the foot of the bed. V8 removed her gloves and applied new gloves without hand hygiene. During peri-care to R12's labia, V9 removed her gloves and applied new gloves that she reached into her pocket to retrieve without performing hand hygiene. V9 then provided peri-care to R12's buttocks, V9 wiped one area of R12's buttock then removed gloves and applied new gloves without performing hand hygiene, multiple times. V9 covered R12 with blanket while R12 still had urine saturated gown on. V8 pulled cover down and removes the urine saturated gown and then applies clean gown without changing gloves or performing hand hygiene. Policy titled Incontinent Care states, all residents with incontinency shall receive perineal care following any episode of incontinency. Same, document states, purpose as the following: To reduce the incidence of UTI as a result of cross contamination. To reduce the incidence of increased skin breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 If continuation sheet Page 2 of 10 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott County Nursing Center Rural Route 2 Winchester, IL 62694 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review an interview the facility failed to employ a Registered Nurse, (RN), in the facility for 8 hours a day, 7 days a week. This has the potential to affect all 34 residents at the facility. Residents Affected - Many Findings include: 1. The facility nursing schedule dated 01/29/2023-02/21/2023 documents the facility did not have an RN 8 hours a day on 01/29/2023, 02/11/2023, 02/12/2023 and 02/20/2023. On 02/22/2023 at 9:51AM V2, Director of Nursing, (DON), stated, the facility did not have an RN on duty at the facility on 01/29/2023, 02/11/2023, 02/12/2023 and 02/20/2023. On 02/22/2023 at 11:20AM, V1 Administrator stated, the facility does not have a specific staffing policy, but is documented in the resident admission packet. V1 stated, the facility follows stated guidelines. The facility important facts dated January 25, 2022, documents, staffing, it is the intention that all units of the facility are staffed in a manner appropriate to the needs of the residents. Guidelines from various entities (The Center for Medicaid/Medicare Services, and the Illinois Department of Public Health) are considered when determining appropriated staffing levels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 If continuation sheet Page 3 of 10 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott County Nursing Center Rural Route 2 Winchester, IL 62694 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview, observation and record review, the facility failed to store dry goods properly, handle utensils in sanitary manner and ensure the ice machine had an air gap. This failure has the potential to affect all 34 residents living in the facility. Findings include: 1. On 02/23/23 at 10:40AM, V22, Dietary Aide, washed her hands, then as she was talking, kept touching her face mask. V22 then donned gloves and then began to fill up the plastic silverware bin out of a larger storage bag. V22 removed her gloves, failed to wash her hands and then started to put plastic trays on the food cart. 2. On 02/23/23 at 11:55AM, V16, Cook, was pulling the noon meal out of the oven for temperature checks and then service. V16 grabbed a serving ladle from the overhead hook by the ladle to stir the chicken and check the temperature of the food. V16 repeated this action 4 separate times to check all the hot foods being served. V16 was not wearing gloves. V16 had not washed her hands before each time she grabbed ladles. 3. On 02/23/23 at 12:10PM, on a kitchen storage table a 14-ounce box of Minute Rice, a 28-ounce box of Wheat Cereal, a 36-ounce box of Malt-O-Meal and 42-ounce box of Quick Oats were not sealed properly. All were noted to have an opening which potentially let the food become contaminated. 4. On 02/23/23 at 12:45PM, the facility ice machine did not have an air gap. The ice machine drainage has a flexible tube that runs down into the floor drain approximately 1.5 inches from the bottom of the drain. On 02/23/23 at 2:30PM, V15, Dietary Manager, stated, that she did not notice the boxes of food had an unsealed opening. V15 expects staff to not touch serving utensils at the serving end. V15 did not realize that the ice machine did not have an air gap. V15 also, stated, that hands should be washed before donning gloves and when soiled. The Nutritional Services Department, undated, documents, Utensils, cups, glasses and dishes shall be handled in such a way as to avoid touching surfaces that food or drink will come into contact with. It continues, 25. Dry cereal such as, oatmeal, malt -o-meal, cream of wheat etc. (etcetera), must be put in clear plastic containers with lid after opening. Dated and labeled. The Resident Census and Conditions of Residents, CMS 672, dated 02/21/23, documents that the facility has 34 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 If continuation sheet Page 4 of 10 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott County Nursing Center Rural Route 2 Winchester, IL 62694 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. On 02/21/23 at 03:29PM V7, Certified Nursing Assistant, (CNA), enters R5's room which there was a strong BM, (bowl movement), odor. V7 exits R5's room went to the shower room and retrieved the sit to stand then entered back into R5's room with sit to stand lift. After care of R5, V7, CNA grabbed the soiled laundry and placed it in a bag, then washes her hands with soap and water. Then picks up the dirty bag with no gloves and exits room pushing the lift. V7 pushes the lift down to the shower room and did not cleanse it after placing it back into shower room. Residents Affected - Many V6 CNA exits R5's room with gloves on and then enters R2's room, V6 went to R2's bathroom removes her gloves and throws them in R5's waste can, then washes her hands with soap and water and exits bathroom through R2's room. R5's progress notes dated 02/20/2023 at 10:42AM documents R5 noted to have an increase of occasional loose stools and voiced experiencing nausea. On 02/22/23 at 11:52AM V17, Licensed Practical Nurse, (LPN), stated, she was told if no symptoms or fever for 24 hours residents could come out of room. V17 did state some residents also, had diarrhea as a symptom. The facility policy Infection Control undated policy documents Standard Precautions: standard precautions include the following procedures appropriate cleaning of client care equipment. Based on interview, observation and record review, the facility failed to utilize Personal Protective Equipment, (PPE), isolation trash bags, isolation linen bags, gloves, hand hygiene, multiuse resident equipment and accurate surveillance to prevent the spread of Gastrointestinal Norovirus which is spreading throughout the facility and lack of hand hygiene between gloves changes. This has the potential to affect all 34 residents living in the facility. Findings include: On 02/21/23 at 9:30AM, V1, Administrator, stated, that a stomach virus started this weekend. When questioned as to what they are doing, V1, stated, that the residents are being kept in their rooms and after 24 hours of no symptoms they can come out of their room. V1 stated, that if a resident is symptomatic there will be an orange dot in their doorway. On 02/22/23 at 1:42PM, V10 Infection Preventionist Nurse, stated, V13, County health Department Nurse, was contacted on Monday morning and updated again today about the GI, (Gastrointestinal), outbreak. V10 stated, that she is unsure why staff are not using PPE and that she will obtain the P and P, (Policy and Procedure), for Gastroenteritis. V10 stated, We are keeping them in their rooms for 24 hours after their last symptom. On 02/22/23 at 2:06 PM, V1, Administration, stated, Everyone is working together on this. The nursing staff reporting to me or V10, infection Preventionist about who is sick or showing symptoms. There is no real one person in charge. Over the weekend, residents started to come down with GI symptoms, nothing the same, some had diarrhea, some with nausea and then some with vomiting. I told the staff to keep the symptomatic residents in their rooms, and that they could come out after they had been symptom free for 24 hours. When we came in on Tuesday the nursing staff had all residents eating in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 If continuation sheet Page 5 of 10 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott County Nursing Center Rural Route 2 Winchester, IL 62694 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 Residents Affected - Many their rooms on Styrofoam. Which I did not agree with, that is why lunch was served in the dining room. V1 was questioned about why the staff are not wearing PPE or using isolation bags or laundry isolation bags while working with the symptomatic resident, V1 stated, I guess we should have. V1 stated, I did not have anyone tested for anything. I think this is just a 24-48-hour bug. (V12), Medical Director, is in the building now and he is looking at residents. V1 was questioned if the facility has a Gastrointestinal Norovirus policy, V1 stated, I think so. I will have to look for it. V1 stated, that she expects staff to wash their hands after working with residents, removing gloves, before putting on gloves and between each meal tray delivered. V1 also, stated, that multiple use equipment should be sanitized after it is used on a symptomatic resident. On 02/23/23 at 8:32AM, V1 stated, We have 2 new cases that came down with symptoms last evening R8 and R6. They have been isolated to their rooms and we were able to get a stool sample and I have sent it to the lab as a STAT, (immediately). We should have the results this afternoon. V1 further stated, that residents can come out of their rooms after they have been symptom free for 24-hours. V1 was questioned if she was aware of the CDC, (Center for Disease Control), guidance documenting that resident should be in isolation for 48 hours after the last symptom. V1 stated, that she was not aware of the CDC guidance. On 02/23/23 at 10:10AM, V13, Health Department, stated, The facility did call me on Monday and let me know that they had a few residents and staff having GI symptoms. V1 told me they were isolating the residents. I told them that they need to contact me with updates. V13 was questioned if she was aware of the number of the residents that have come down with symptoms, V13 stated, that she did not realize that many residents were affected. 16 residents noted on log, per GI event tracking Surveillance for Congregate Setting Outbreak Log. V13 was asked about her feeling on residents being let out of isolation after 24-hours, and not using PPE or hand hygiene not being performed. V13 stated, I really didn't delve, (careful or detailed search for information), that much into it when I spoke to them. I am really surprised that the facility is having trouble, because they handled COVID so well. Isolation, PPE and basic handwashing are normal things that should be done. V13 stated, If the facility does not have a policy and procedure, I would think they would go to the CDC and follow their guidance on Gastrointestinal Norovirus. On 02/27/23 at 9:15 AM, V2, Director of Nurses, stated, that all of the soiled linens and trash should have been put in isolation bags. 1. On 02/21/23 at 1:59PM, V7, Certified Nurse Assistant, (CNA), entered R26's room to toilet R26. V7 did not wear a gown. V7 transferred R26 from the wheelchair to the toilet using a partial mechanical lift. R26's room or bathroom has no isolation trash or isolation linen bag. When V7 finished assisting R26 she removed the partial mechanical lift and put it in the 100-hall shower room without disinfecting the lift. V7 stated, that lift is used for the 100 hall. V7 stated, This partial mechanical lift is used only for the 100 hall and each hall has its own. V7 did not cleanse the partial mechanical lift once in the shower room. 2. On 02/21/23 at 2:05PM, V7 went to the 100-hall shower room and obtained the partial mechanical lift, V7 then took the lift to R3's room. R3 was transferred using the partial mechanical lift from her wheelchair to the toilet. V7 failed to wear a gown or gloves. R3's room or bathroom has no isolation trash or isolation linen bag. 3. On 02/22/23 at 1:32PM, V8 CNA came out of R11's room with the partial mechanical lift. V8 stated, that R11 was transferred from the bed to the recliner. V8 failed to cleanse the partial mechanical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 If continuation sheet Page 6 of 10 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott County Nursing Center Rural Route 2 Winchester, IL 62694 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 Residents Affected - Many lift before putting it in the 100-hall shower room. V8 did not cleanse the partial mechanical lift once in the shower room. 4. On 02/22/23 at 8:18AM, V20, CNA, entered R3's room with her meal tray. V20 did not don gloves or a gown. V20 arranged items on R3's tray table to make room for the meal tray and then assisted R3 with sitting up straight in her wheelchair. V20 exited the room without hand hygiene. V20 then went to the breakfast cart in the hallway and obtained R12's (R3's roommate) meal tray. V20 did not don gloves or a gown. V20 assisted R12 up to the bedside and set the breakfast tray up for R12. 5. On 02/22/23 at 11:25AM, V8 and V18 CNAs entered R31's room to provide R31 with incontinent care and getting her up in her wheelchair. Both V8 and V18 failed to perform hand hygiene before donning gloves or wear a gown. V18 left the room with her gloves on, went to shower room to get an incontinent brief, V18 came back to the room, with the same gloves removed soiled incontinent brief, wiped R31's left and right groin, pubic area and labia, changed gloves with no hand hygiene in between, rolled R31 over and cleansed the buttocks and rectal area. V18 changed gloves with no hand hygiene in between. R31 was dressed and then put in her high back reclining chair using a mechanical lift. R31's room did not have isolation linen or isolation trash in her room or bathroom. On 02/22/23 at 11:35AM, V18 stated, (R31) has not had any loose stools or nausea or vomiting today but, she did have some yesterday. On 02/22/23 at 12:15PM, R31 was in the dining room being assisted with her meal. 6. On 02/22/23 at 12:00PM, V16, Dietary Cook, was observed passing the lunch trays on the hallway. V16 set up the residents for the meal service. V16 did not utilize hand hygiene or gloves between residents. V16 did not use a gown either. V16 served R7, then to R13's room, then to R19's room, then to R23's room, then to R16's, then to R3, then to R25's room, then to R2 room and finished in R137's room, passing lunch trays and did not utilize hand hygiene or gloves between any of the residents. 7. On 02/21/23 at 11:44AM, V5, Licensed Practical Nurse, (LPN), gave R2 her noon medications. V5 stated, that R2 is having stomach issues. V5 did not wear a gown or gloves. After R2 took all the medications, V5 took the medication cups grabbing the top of lip of the cup with her bare hands and threw the cups away. V5 exited the room and did not perform hand hygiene. 8. R11's Progress Note, dated 02/22/23 at 4:40PM, documents, resident stayed in bed for breakfast and lunch. She did have loose stools x's 3 this shift. She was assisted up to her recliner this afternoon and is alert and oriented x's 2 per her normal. Denies stomach upset or pains. fluids encouraged. Due meds as ordered. PRN, (as needed), Imodium given with some relief as has not had any loose stools this afternoon. Will con't, (continue), to monitor. Afebrile T, (temperature), - 97.6. On 02/22/23 at 1:05PM, R11's room was entered, V9, Certified Nurse Aide (CNA), was providing incontinent care for R11. V9 had placed a soiled urine and feces disposable pad and disposable incontinent brief on R11's bathroom counter and sink area. V9 was not wearing a gown during the incontinent care. V9 changed her gloves, 2 times without hand hygiene. After completing the care, V9 then collected the soiled linens off the counter and sink and placed them in her right hand extending up her foreman and held the soiled linens against her shirt. V9 went into the shower room and placed the soiled linens onto the soiled linen barrel lid. V9 removed her gloves and failed to sanitize her hands. V9 then raised the soiled linen barrel lid and placed the soiled linens in it and discarded the trash. V9 did not clean the soiled linen barrel lid or R11's bathroom counter or sink. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 If continuation sheet Page 7 of 10 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott County Nursing Center Rural Route 2 Winchester, IL 62694 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 Residents Affected - Many The facility supplied document, Transfer and Ambulation, dated 02/27/23, documents that R16, R11, R5, R8, R26, R10, R18 and R19 all use the partial mechanical lift. The facility GI event tracking Surveillance for Congregate Setting Outbreak log dated 02/22/23, documents R2, R14, R10, R11, R5, R31, R16, R23, R28, R3, R12, R13, R26, R87, R7 and R25 all were affected with GI symptoms of diarrhea, nausea, vomiting or elevated temperature. 02/22/23 10:40AM interview with V1 and V10 stated, they would put together the log for the residents with GI symptoms. V1 stated, I have a handwritten list of them that the nurse told me was sick over the weekend. 10. R12's Minimum Data Set, (MDS), dated [DATE] documents a brief interview of mental status of 4, which indicates R12 is severely impaired. MDS documents that R12 is dependent with bathing, dressing, toileting, transfers and personal hygiene. R12's progress notes dated 02/21/23 at 9:28PM documents, R12 had Diarrhea stool x1 this shift. Did eat snack tonight. Has been in bed most of day. R12 is listed on the facility provided event GI log as having loose stools on 02/21/23. On 02/22/23 at 11:47AM V8 and V9 performed peri care on R12. V8 entered room and put gloves on. V9 entered room and washed hands and applied gloves. V8 sat R12 on edge of bed and applied gait belt. R12 then stood her up and V9 removed saturated incontinent brief and bed pad. V9 handed saturated linens to V8 and V8 placed linens on floor. V9 then put a clean incontinent bed pad on bed. V8 assisted R12 to lay down on the incontinent bed pad. R12 was laying on her back with her hands on her chest. V8 pulled R12's gown up to R12's chest and laid it on her hands and chest. R12's gown was saturated with urine. V8 then picked up urine saturated linen off the floor and put it in a plastic bag on the foot of the bed. V8 removed her gloves and applied new gloves without hand hygiene. During peri-care to R12's labia, V9 removed her gloves and applied new gloves that she reached into her pocket to retrieve without performing hand hygiene. V9 then provided peri-care to R12's buttocks, V9 wiped one area of R12's buttock then removed gloves and applied new gloves without performing hand hygiene, multiple times. V9 covered R12 with blanket while R12 still had urine saturated gown on. V8 pulled cover down and removes the urine saturated gown and then applies clean gown without changing gloves or performing hand hygiene. 11. R19's MDS dated [DATE] documents, a brief interview of mental status of 3 which indicates R19 is severely impaired. MDS documents that R19 needs assist with bathing, dressing, toileting, transfers and personal hygiene. R19's diagnosis include, Primary osteoarthritis, unspecified site (Primary), Type 2 diabetes mellitus without complications, Pain, unspecified, Gastro-esophageal reflux disease without esophagitis, Other kyphosis, site unspecified, Edema, unspecified, Personal history of COVID-19, Major depressive disorder, single episode, unspecified. R19's Progress Note dated 02/22/23 at 5:44AM documents, R19 Diarrhea stool x 1 this a.m. Colace held. States feels ok denies any nausea at this time. Will continue to monitor. On 02/22/23 at 11:08AM V19 performed peri-care on R19. R19 is currently experiencing diarrhea and has been eating in her room. V19 states, that no one has told her to wear any other PPE when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 If continuation sheet Page 8 of 10 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott County Nursing Center Rural Route 2 Winchester, IL 62694 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 providing care to R19 except gloves and hand hygiene. Level of Harm - Minimal harm or potential for actual harm R19's Progress Note dated 02/22/23 at 4:59PM documents, R19 has had loose stool x's 2 this shift. She denies feeling ill. No nausea. Appetite per her normal. Takes due meds as ordered. No s/s of distress, is afebrile T-97.9, will con't to monitor and assist with cares as needed. On 02/23/23 R19 is not on the facility provided GI event tracking log. Residents Affected - Many 12. R23's MDS dated [DATE] documents a brief interview of mental status of 12 which indicates R23 is moderately impaired. MDS documents that R23 needs limited assist with bathing, dressing, toileting, transfers and personal hygiene. R23's diagnosis include: Paroxysmal atrial fibrillation (Primary), Chronic diastolic (congestive) heart failure, Type 2 diabetes mellitus without complications, Chronic kidney disease, stage 3, unspecified, Peripheral vascular disease, unspecified, Unspecified macular degeneration, Essential (primary) hypertension, non-ST elevation (NSTEMI) myocardial, infarction, Atherosclerotic heart disease of native coronary artery without angina pectoris, Dilated cardiomyopathy, Dysphagia, unspecified, History of falling, Presence of aortocoronary bypass graft, Presence of automatic (implantable) cardiac defibrillator, Depression, unspecified, Hyperlipidemia, unspecified, Metabolic encephalopathy, other specified hypothyroidism. On 02/21/23 at 9:00AM R23 stated, that he has had diarrhea a few times over the weekend, and he has had to stay in his room. Facility provided event tracking log on 02/23/23 at 12:00PM documents, R23 on log as having diarrhea and as being cleared of symptoms on 02/22/23. R23 Progress Notes on 02/23/23 at 7:14PM documents R23 had loose stool x's 1 early this shift Imodium given per prn order. No further loose stools. Resident denies any c/o. Afebrile T - 97.4, due meds as ordered. Up in room per his normal. No s/s of distress will con't to monitor. R23 Progress Notes on 02/22/23 at 4:27PM documents, R23 up in his room today. He states, he is feeling better and does not feel unwell, he has had 2 watery stools this shift, is afebrile T - 97.8. and takes due meds without difficulty. No s/s, (Signs or Symptoms), of A/R, (autoimmune and inflammatory disease), appetite is good, will con't to monitor and assist as needed. R23 progress notes on 02/22/23 at 4:46AM documents, R23 Diarrhea x2 this shift. Encouraged to take fluids, will continue to monitor. R23 progress notes on 02/18/23 at 7:38PM documents, R23 vomited x2 with large emesis. Resident having loose stools x3. Writer sat resident up in bed and encouraged resident to sip on water when needed and rest his stomach. Resident a/ox4 and replied, ok I will do that, thank you Writer provided saltine crackers, will cont to monitor. The facility policy Infection Control undated policy documents Standard Precautions: standard precautions include the following procedures appropriate cleaning of client care equipment. The facility Infection Control policy, undated, documents, Handwashing is the single most effective way to reduce the number of microorganisms on the surface of the skin. It should always be performed: before and after contact, before and after using gloves, after contact with used equipment. Body Protection: Gown and clothes such as overalls will reduce the possibility of contact with hazardous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 If continuation sheet Page 9 of 10 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott County Nursing Center Rural Route 2 Winchester, IL 62694 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 Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete or contaminated substances. They also will protect from contact with microorganisms. Paper gown. Wear to protect self from infectious resident. Wear to protect resident from possible exposure to microorganisms. Ties at the neck and waist. Tie securely. Discard after use. Change between residents. Linen Handling. Appropriate personal protective equipment's should be worn when handling soiled linen with bodily substances. Linen that is heavily soiled with blood or other bodily substances should be in leak proof bags and securely tied. Hands should be washed after handling used linen. Event ID: Facility ID: 146106 If continuation sheet Page 10 of 10