Country Health: Incontinence Care Failures Found - IL
Inspectors documented the situation on May 23, 2026. They had been watching since 8:45 that morning. At 10:53 AM, two certified nurse aides finally brought the resident, identified in inspection records as R2, to her room and lifted her into bed using a mechanical sling. What they found when they began care: she was incontinent of both urine and bowel. Her skin told the rest of the story.
The inspection report describes baseball-sized dark reddened areas on both of her sitting bones and her tailbone. Her buttocks showed multiple red lines and wrinkled impressions pressed into the skin from the mechanical lift sling she had been sitting on for an extended period. The odor, inspectors wrote, was extremely foul and permeated the room.
The two aides did not change their gloves once during the entire process. They did not perform hand hygiene. They moved from soiled skin to clean without stopping.
At 11:10 that morning, one of the aides told inspectors she had last provided incontinence care at 7:30 AM, then helped the resident to the dining room for breakfast. After that, nothing. Three hours and twenty-three minutes had passed. "I should have provided incontinence care every two hours but got busy and did not have time to check on R2," she said.
She also told inspectors that R2's urine had smelled strongly for a long time.
R2 is severely cognitively impaired, according to her most recent assessment on file. She cannot voice her own toileting needs. She depends entirely on staff for personal hygiene and toileting, and requires maximum assistance to transfer. She also carries diagnoses of atrial fibrillation, type II diabetes, muscle wasting, generalized weakness, and unsteady gait. She is not a resident who can ask for help, shift her own weight, or clean herself.
The Director of Nurses acknowledged the following day that staff who are not checking residents have no way of knowing whether they are wet or soiled. "The staff would not know if the resident is incontinent or not if the staff are not checking them," she told inspectors on May 24. She added that even when a resident is dry at the two-hour mark, repositioning is still required to reduce the risk of pressure ulcers from prolonged sitting in one position.
The reddened areas on R2's tailbone and sitting bones suggest that repositioning had not been happening.
Cross-contamination during incontinence care carries direct risk of urinary tract infection, particularly for residents who are already incontinent of bowel. Moving between contaminated and clean areas without changing gloves or washing hands is the mechanism by which bacteria transfer. R2's urine had reportedly smelled foul for an extended period before inspectors ever walked through the door.
Country Health is a small facility. The nurses station sits directly across from the common area where R2 spent that entire morning facing a window. The inspection report does not indicate that any staff member approached her during those two hours and eight minutes of observation.
The complaint inspection, completed May 26, 2026, cited the facility for failing to provide timely incontinence care, failing to prevent cross-contamination during that care, and failing to provide appropriate care to prevent urinary tract infections. Inspectors classified the level of harm as minimal harm or potential for actual harm.
The reddened areas were already there when the aides arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Health from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 17, 2026 · Our methodology
COUNTRY HEALTH in GIFFORD, IL was cited for violations during a health inspection on May 26, 2026.
Inspectors documented the situation on May 23, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.