Health inspection·February 21, 2025

F 0583 approximately 1 hour. Level of Harm - Minimal harm or potential for actual harm On 2/21/25 at 12:40 PM, R1 stated he felt exposed while staff were providing care. R1 said due to feeling exposed he had asked if they would put his pants on and they had refused. Residents Affected - Few On 2/21/25 at 3:10 PM, V2 (Director of Nursing/ DON) stated it is the expectation that staff provide privacy when providing care. The facility's revised 9/11/20 Perineal/ Incontinence Care policy documented in part .Procedure . 1. Gather equipment for procedure . 3. Provide privacy . 6. Assist with position [sic] the resident into a safe and comfortable position; avoid overexposing the resident's body . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146124 If continuation sheet Page 2 of 5 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 146124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White County Rehab and Nursing 615 West Webb Street Carmi, IL 62821 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 observation, interview, and record review the facility failed to provide perineal, urinary catheter, and wound care per standards of practice to prevent infections for 1 (R1) of 3 residents reviewed for infection control in a sample of 3. Residents Affected - Few Findings include: R1's admission Record documented an admission date of 10/8/24 with diagnoses including enterocolitis due to clostridium difficile, local infection of the skin and subcutaneous tissue, flaccid hemiplegia affecting right dominant side, cerebral infarction. R1's 11/20/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R1 was cognitively intact. The same MDS documents that R1 is dependent for toileting hygiene, toilet transfers, and chair to bed transfers. R1 has an indwelling catheter, and R1 is always incontinent of bowel. R1's Care Plan documents a focus area of I currently have an infection d/t (due to) C-Difficile (clostridium difficile) with an initiation date of 01/28/2025. Documented interventions for this focus area include: Emphasize good hand washing techniques to all direct care staff and type of isolation: contact enteric precautions. R1's Care Plan also documents a focus area of I have an Indwelling Urinary Catheter and am at risk for opportunistic infection to enter my body with an initiation date of 12/26/24. Documented interventions for this focus area include: Enhanced Barrier Precautions during personal care. On 2/21/25 at 10:45 AM, V4 (Certified Nursing Assistant/ CNA) and V5 (CNA) completed hand hygiene and donned gowns and gloves then assisted R1 from his wheelchair to the bed with a mechanical lift. V5 removed R1's pants soiled with feces and pulled R1's urinary catheter collection bag trough the pant leg. V5 placed the urinary catheter collection bag on the fitted sheet. V4 took R1's soiled pants and placed them in a clear bag. V5 pulled down the front of R1's incontinence brief and fecal matter was noted to be on R1's lower stomach, groin folds, scrotum, and urinary catheter tubing. V5 used a blue plastic disposable under pad sprayed with peri wash to clean the feces off of R1 groin folds wiping from front to back and would wad up the dirty area of the disposable under pad and wipe again. V5 continued to clean feces from R1 with the disposable under pad with a wipe and wad method. V4 and V5 assisted R1 to roll to his side with some feces left on the urinary catheter tubing. V5 changed her gloves without preforming hand hygiene and removed the feces soiled incontinence brief. V5 proceeded to clean feces from R1's gluteal folds with a disposable under pad with peri wash sprayed on it with the same wipe and wad method. The bottom of the back of R1's shirt had feces present and the cloth pad under R1 was soiled with feces when V4 and V5 assisted R1 to roll onto his back. V5 changed her gloves but did not perform hand hygiene. V5 sprayed another disposable under pad with peri wash and wiped R1's groin folds and scrotum with the same wipe and wad method. V5 was observed to handle the bottle of peri wash with her soiled gloves several times replacing it on the bedside table or setting the bottle on the soiled pad. V5 sprayed another disposable under pad with peri wash and began cleaning R1's urinary catheter tubing then retracted R1's foreskin to clean R1's glans penis with the same wipe and wad method, continuing with the same disposable pad soiled with feces, V5 encircled R1's urinary catheter tubing at R1's urinary meatus and without holding the tubing to prevent traction pulled the disposable pad down the catheter tubing. V5 pulled the disposable under pad down R1's catheter tubing twice without holding the tubing to prevent traction. R1's urinary catheter was observed to move in and out of the urethra while V5 was cleaning the tubing and would back into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146124 If continuation sheet Page 3 of 5 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 146124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White County Rehab and Nursing 615 West Webb Street Carmi, IL 62821 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 - Few urethra when V5 released the tubing. V4 sat the bottle of peri wash on the bedside table where it was originally located. V4 and V5 said they were then waiting on V8 (Licensed Practical Nurse/ LPN) to complete wound care for R1 before they put a clean incontinent brief on R1. V5 then grabbed R1's door handle with her soiled gloves and opened R1's door looking for V8 then shut the door. V4 was asked if she usually used disposable under pads to provide perineal and urinary catheter care and V4 said not usually but the facility did not have any clean washcloths at this time to clean residents with. On 2/21/25 at 11:15 AM, V8 (LPN) entered R1's room with wound care supplies sitting them on the uncleaned bedside table. V8 and V4 assisted R1 to roll to his side and V8 sat R1's wound supplies on R1's feces soiled cloth pad. V8 told V4 R1 needed a clean cloth pad and V4 with the same soiled gloves opened R1's door and told V5 to bring another cloth pad and shut the door. While waiting for V5 to bring the cloth pad, V8 picked up wound care supplies from the soiled cloth pad and set them on the fitted sheet. V8 then sprayed wound cleaner on gauze 4x4 and started to pick pieces of feces from R1's thighs, buttocks, gluteal fold, and lower back. V5 opened R1's door and handed V4 a cloth pad. V8 performed hand hygiene and donned clean gloves, returned to R1's bedside and V4 with the same soiled gloves handed the cloth pad to V8. V8 rolled the soiled pad up and placed the clean cloth pad under it. V4 and V8 assisted R1 to roll to the other side and V4 removed the soiled pad. V4 and V8 assisted R1 to roll to the other side, still with feces on the bottom of the back of R1 shirt, to allow V8 to provide wound care. V8 performed hand hygiene and donned clean gloves before picking up the wound care supplies sitting on R1's fitted sheet and cleaned R1's right buttock wound. V8 performed hand hygiene and donned clean gloves before picking up the other wound care supplies from R1's bedside table and sitting them on R1's fitted sheet. V8 packed R1's wound and covered with a boarder dressing. V8 sprayed wound cleaner on gauze 4x4 and wiped more pieces of feces off of R1's upper thighs. On 2/21/25 at 11:35 AM, a knock sounded on R1's door, V4 with the same soiled gloves opened the door and V6 (CNA) and V7 (CNA) entered R1's room wearing gloves and gowns. V8 performed hand hygiene and V4 doffed her soiled gloves, without performing hand hygiene V4 opened R1's door and V8 and V4 exited. V4 closed R1's door by grabbing the outside handle. V7 picked up R1's urinary catheter collection bag and attempted to put it down a pant leg of a new pair of pants, not knowing R1's urinary catheter collection bag privacy cover was soiled with feces. V7 was asked if R1's urinary catheter collection bag privacy cover was clean and V7 said she thought that it had some dirt on it and removed the privacy bag and put the collection bag through the pant leg. Without performing hand hygiene or donning new gloves V7 picked up a clean incontinence brief and set it on the fitted sheet. V7 and V8 assisted R1 to roll to his side. V7 then picked up a towel and sprayed it with peri wash and cleaned more feces from R1's thighs, gluteal fold, and lower back. V7 rolled half the incontinence brief and placed it under R1's bottom. V7 an V8 assisted R1 to roll and V8 unrolled the other side of the brief under R1, then assisted him to roll onto his back. V8 sprayed another towel with peri wash and cleaned feces from R1's lower abdomen and groin folds. V7 and V8 closed the incontinent brief and assisted R1 to pull up his pants. V7 and V8 were asked if the back of R1's shirt had feces on it. V7 and V8 assisted R1 to roll to his side and said R1's shirt did have feces on it. V7 and V8 assisted R1 in removing his shirt and placed it in a clear bag. V8 went to R1's closet and retrieved a clean shirt, then V7 and V8 assisted in putting on the clean shirt. On 2/21/25 at 3:00 PM, V2 (Director of Nursing/ DON) said staff should follow the facility policy for infection control standards when performing perineal, urinary catheter, and wound care. The facility's revised 9/11/20 Perineal/ Incontinence Care policy documented in part .Procedure . 1. Gather equipment for procedure . 7. Remove soiled brief/ underpad from resident by rolling the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146124 If continuation sheet Page 4 of 5 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 146124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White County Rehab and Nursing 615 West Webb Street Carmi, IL 62821 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 - Few brief/ underpad to contain as much fecal matter as possible. If gloves visibly soiled or you touch stool, remove gloves, complete hand hygiene and don new gloves . 8. Cleanse the resident's perineal area using an approved no-rinse incontinence cleansing product, soap and water, or wipes . b. For male residents, retract the foreskin if uncircumcised then clean the tip of the penis using a circular motion starting with the urethra and working down the shaft. i. The shaft, scrotum, rectal area and buttocks should be cleaned as well. 9. Use a clean area of cloth for each area cleansed. Use multiple cloths, if necessary, to maintain infection control practices . 11. Remove gloves and perform hand hygiene and apply clean gloves. 12. Change pad under resident if not changing pad during the perineal process paying attention to not contaminating new pad with soil from old pad . The facility's undated Catheter Care policy documented in part . 7. Perform perineal/ incontinence per facility policy prior to catheter care . 10. For a male resident, retract the foreskin of the uncircumcised penis to expose the urethral meatus and catheter insertion site. Clean from the tip of the penis down the shaft of the penis. Use a different area of the wash cloth for each wipe. Clean from the resident outward on the catheter 4-6 inches using clean area of cloth. Being careful not to place traction on the tubing. Maintain hand position throughout the procedure. Replace the foreskin. 11. Place securement device if appropriate for the resident as nursing measure . The facility's revised 11/9/19 Wound Care policy documented in part . General Guidelines . 3. Gather equipment. 4. Place items on a clean surface . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146124 If continuation sheet Page 5 of 5