Inspection·December 12, 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 interview, observation, and record review the facility failed to perform hand hygiene, change gloves when needed, and have signage indicating the need for Enhanced Barrier Precaution, for 5 of 16 residents (R12, R13, R21,R25, R27) to prevent cross contamination reviewed for infection control in the sample of 29. Residents Affected - Some Findings include: 1. On 12/11/24 at 9:24 AM, V15, Certified Nurses Aide, (CNA) and V8 CNA both donned gloves without hand hygiene. V8 and V15 transferred R25 from her reclining geriatric chair to her bed using a full mechanical lift. Once in bed, R25's pants and incontinent pad were removed. V8's groin, labia, and meatus was cleaned with premoistened peri-wash cloths with the same gloves. V8 touched R25's leg and shoulder to assist with rolling over onto R25's side. V8 with pre-moistened peri-wash cloths cleansed the rectal area and buttocks. V8 placed a new incontinent pad, straightened R25's night gown, pillow, covers, and removed her gloves but did not wash her hands. V8 using the bed control lowered the bed, removed the trash bag from the can, inserted a new bag, left room, went up the hall, placed the trash in the soiled utility room, and went and got R13 in her geriatric reclining wheelchair and pushed her to her room with no hand hygiene. R25's Face Sheet, print date of 12/11/24, documents that R25 was admitted on [DATE]. On 12/11/24 at 3:50 PM, V15 CNA stated that she just forgot to wash her hands before putting on gloves and taking them off. On 12/11/24 at 4:00 PM, V1, Administrator, stated that she expects staff to perform hand hygiene before putting on gloves, after removing gloves and whenever they need it. 2. On 12/11/24 at 9:38 AM, V8 pushed R13 into her room to transfer R13 to bed. V15 was present to assist. V8 and V15 transferred R13 to bed using a full mechanical lift. V8 and V15 both donned gloves with no hand hygiene. R13's Face Sheet, print date of 12/11/24, documents that R13 was admitted on [DATE]. 3. R21's Face Sheet, undated, documents R21 was originally admitted to the facility on [DATE] with diagnosis of Hemiplegia/Hemiparesis and Dysphasia following Cerebral Infarction, Metabolic Encephalopathy, Dementia, and Urinary Tract Infection (UTI). R21's Care Plan, dated 12/10/24, documents R21 required assist with daily care. R21 is incontinent of bowel and bladder. Interventions: Check for incontinence at least every two hours and PRN (as (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 3 Event ID: 146106 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 12/12/2024 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)