Inspection·January 25, 2024

F 0684 Level of Harm - Actual harm Residents Affected - Few R9's Progress Note, dated 06/27/2023 12:42 AM, (V2 Director of Nurses, (DON)) and V1, (Administrator), were both made aware of the fx (fracture) at the time of the xray report return in the evening by the previous nurse. R9's Progress Note, dated 06/27/2023 10:08 AM, documents, Called and spoke with (V19, Doctor) nurse regarding x-ray results, states (V19) wants her to see ortho (orthopedics). R9's Progress Note, dated 06/28/2023 03:30 AM, documents, Resident has slept during the night. Does not complain of pain unless she is being turned and repositioned and then will subside after she lays still. Resident did take liquids for staff without any problems. R9's Progress Note, dated 06/30/2023 11:00 AM, documents, Resident returns via mass transit from ortho appt. It continues, Direct staff accompanying. Resident returns in wheel chair with immobilizer sling to right arm. Resident responds appropriately. Denies pain in right shoulder N.O may remove for bathing, avoid lifting arm above shoulder height. No PT (Physical Therapy) on right upper extremity and no use of right extremity. R9's Medical Record fails to document any pain, discomfort or assessment for R9 on 6/23/23, 6/24/23 or 6/25/23. R9's Right Shoulder Xray, dated 6/26/23, documents, Acute fracture of the distal clavicle. R9's Resident Incident Investigation Report, dated 6/26/23, documents V2, DON's, interviews with staff. Care givers interviews prior to discovery of injury: 6/23/23: (V8, Certified Nurse Aide, (CNA)), stated on Friday about 1130 she has got (R9) up for lunch. when getting her up she kept saying that her arm was broke and hurting. she didn't notice any bruising, reported to (V22, Licensed Practical Nurse, (LPN)) that she was saying that her arm was broke and hurting. (V17, CNA) overheard resident say she was hurting in her shoulder at lunch on Friday, seen nurse (V22) give her meds (medication) and then resident was taken by another CNA to lie down in her bed. (V15, CNA) seen resident leaning in chair in dining room and went to help set her back up and resident said her shoulder was broke and crying, told nurse (V22). (V22) (Unknown) CNA reported resident having shoulder pain, assessed and found no redness, bruising or marks on the area, was able to push staff away as she did not want staff near her, resident then taken to bed to lay down. (V18 LPN) resident c/o pain in shoulder, hurting but did not see anything abnormal when looking at shoulder, no bruising seen. 6/24/23: (V19, CNA) aware of pain in shoulder per other staff members. (V20, CNA) aware resident is painful in shoulder. (V21, CNA) gave resident a shower and seen light yellow bruising to R (right) shoulder, nurse informed, c/o pain while in shower. (V23, CNA) helped with getting resident up for shower, resident was c/o right should pain, screaming, told nurse (V22), site was assessed and wasn't red or swollen, but was tender to touch, pain medication was given per nurse. (V24, CNA) assisted with resident on Saturday, voiced c/o right shoulder pain while eating supper and taken to lie down in bed. Resident hurt with taking sweater off and putting her gown on, once laying her down it helped ease her pain to prop her shoulder with small pillow. She slept on her back where she normally sleeps on her right side. With transfers she could cry out it hurt and voiced pain in her shoulder. (V22, LPN) residents c/o pain with transfer, observed in shower with not redness or swelling, had no c/o pain without movements, was up for meals. (V18, LPN) looked at shoulder with nurse (V22, LPN), area was noted at shoulder to have a pink/ tiny bit of brown discoloration but did appear bruised, felt as though it was an area of inflammation. 6/25/23 (V22, LPN) assessed and noted darkness to shoulder, c/o pain with transfers, able to move extremity independently with guarding, shoulder slightly warm to touch, relief with rest, no c/o pain without movements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 0684 On 1/24/24 at 2:45 PM, V2, Director of Nurses, was questioned if there were any written assessments available for review on R9 between 6/23/23 and 6/25/23, V2 stated, No there is not. Level of Harm - Actual harm Residents Affected - Few On 1/24/24 at 2:55 PM, V1, Administrator, stated that she agreed that R9's Doctor should have been notified of R9's pain before 6/26/23. On 1/25/24 at 10:19 AM, V22, stated that at the time she would have assessed her but if she did not find anything alarming she would not have done a written assessment. V22 stated, You know older people generally have aches and pains. The policy on Contacting a Physician, dated 8/14/18, documents, When a change in condition (depending on severity) occurs in a resident, the resident's personal physician or the on-call physician will be contacted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 Based on interview, observation and record review, the facility failed to disinfect a multiple resident use blood glucose monitor to prevent contamination for 2 of 3 residents (R2, R16) reviewed infection control in the sample of 34. Residents Affected - Few Findings include: On 1/23/24 at 11:54 AM, V4, Licensed Practical Nurse (LPN), entered R2's room. V4 obtained R2's blood glucose level. V4 took the blood glucose monitor back to her medication cart and laid it on top. V4 retrieved a Sani wipe (disinfecting wipe) and with 3 quick swipes cleansed the blood glucose machine and then placed it in the top drawer of the medication cart. On 1/24/24 at 11:00 AM, V5, LPN, obtained a blood sugar blood level for R16 using a blood glucose monitor. After completing the test, V5 took the monitor and went to R2 and obtained a blood sugar level on R2. V5 failed to cleanse the machine between the use of R16 and R2. After completing the test V5 grabbed a Sani wipe to cleanse the monitor with, V5 stated, Oh, I didn't clean that off did I. I got distracted. On 1/24/24 at 4:10 PM, V1, Administrator, stated that she had just in-serviced all the nursing staff to keep the monitor wet for the needed contact time. The facility supplied list of residents that receive blood glucose monitoring, dated 1/20/24, documents that R2, R16 and R22 receive blood glucose monitoring. The Sani wipe container documents that to disinfect, the item needs to have a wet contact time of 2 minutes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 If continuation sheet Page 4 of 4