Hammond-henry District Hsp

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

agency, it was my word against hers (V3).The Immediate Jeopardy was identified to have begun on 10/1/25, at 12:30 a.m., when V3 was abusive to Resident R1 during cares. On 10/07/25 at 3:35 p.m. V1/Chief Nursing Officer, V2/Director of Nursing-DON, V15/Risk Manager, and V16/Chief Executive Officer were notified of the Immediate Jeopardy.On 10/08/25 at 10:56 AM the facility submitted the abatement plan.On 10/08/25 at 1:48PM a phone conversation was had with the Facility concerning the submitted abatement plan.On 10/08/25 at 3:16PM the Facility submitted a revised abatement plan.On 10/08/25 at 4:22PM the Regional Office requested a revision to the abatement plan.On 10/08/25 at 5:04PM the Facility submitted a revised abatement plan.On 10/09/25 at 8:37AM the Regional Office requested a revision to the abatement plan.On 10/09/25 at 9:11AM the Facility submitted a revised abatement plan.On 10/09/25 at 10:31AM the Regional Office requested a revision to the abatement plan.On 10/09/25 at 11AM the Facility submitted a revised abatement plan, and the abatement plan was accepted.On 10/09/25 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1.On 10/2/25, V3's employment, with the facility, was terminated.2.10/2/25 at 1150 V2/DON and V15/Risk Manager performed visual assessment of resident (Resident R1) for signs of physical and emotional abuse, no physical marks noted and patient's emotional status unchanged.3.On 10/8/25 V1/Chief Nursing Officer-CNO, V2, and V15 reviewed LTC/Long Term Care Abuse and Neglect Procedures Policy as well as the organization's Behavior Standards.4.V2 reviewed the LTC Abuse and Neglect Procedures Policy and Behavior Standards with the V18/Assistant Director of Nursing-ADON and then all staff on shift on 10/08/25 day shift was educated.5.Staff not working day shift 10/8/25 were called by V18 and V2 and the LTC Abuse and Neglect Policy and Behavior Standards, specific to compassion and empathy, were reviewed.6.Remainder of staff not working or reached by phone on 10/8/25 will be required to receive education on LTC Abuse and Neglect Policy and Behavior Standards, specific to compassion and empathy, prior to working next shift by the V2 or V18 and will be tracked on sign-in sheet.7.Long Term Care Abuse and Neglect Procedures Policy was added by the V2 to contracted staff orientation packet for review prior to first shift, completed on October 8th, 2025.8.On 10/8/25 an Emergency QAPI/Quality Assurance Performance Improvement discussion was held with V1/Chief Nursing Officer, V2, V17/Social Services Director-SSD, V20/ Medical Director and V15 to review the resident audit findings performed and review investigation. On-going audit plan was created. Five residents a month will be interviewed by Social Services or V2 or designee about cares received and any concerns regarding cares. These audit findings will be reported monthly on the QAPI scorecard and reported at the quarterly Quality assurance meetings.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hammond-Henry District Hsp

600 North College Avenue Geneseo, IL 61254

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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information. V2 and V18 then educated all staff on shift on 10/8/25 day shift of the above stated policy.6. Staff not working day shift 10/8/25 were called by V18 and V2 and the LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to the V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information.7. Remainder of staff not working or reached by phone on 10/8/25 will be required to receive education on LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to the V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information. prior to working next shift by V2 or V18 and will be tracked on sign-in sheet.8. LTC Abuse and Neglect Procedures Policy was added by the V2 to contracted staff orientation packet for review prior to first shift, completed on October 8th, 2025.9. 10/8/25 An Emergency QAPI/Quality Assurance and Performance Improvement discussion was held with V1, V2, V17/Social Services, V20/Medical Director and V15 to review the resident audit findings performed and reviewed investigation. On-going audit plan was created, to include monitoring of any concerns/complaints to ensure appropriate follow-up to include reporting of any abuse per policy. five residents a month will be interviewed by Social Services or V2/designee about cares received and any concerns regarding staff. These audit findings will be reviewed by V17 and the V2 and reported monthly by the V2 on the QAPI scorecard and at

the quarterly Quality assurance meeting.10. V15 will monitor all incidents of patient injury and meet monthly with V2 to review for trends for further review.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hammond-Henry District Hsp

600 North College Avenue Geneseo, IL 61254

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Based on observation, interview, and record review, the facility failed to ensure staff change gloves during incontinence care for one resident (Resident R1) of three residents, reviewed for incontinence care, in a total sample of three.Findings include:The video recording, taken in Resident R1's room, on 10/1/25, at 12:30 a.m., shows V3/Certified Nursing Assistant-CNA (employment terminated and unavailable for interview) providing incontinence care (with the assistance of V6/CNA) to Resident R1. Without changing gloves, V3: lowered the bed; pulled down the blankets; pulled out the pillow from underneath Resident R1's buttocks; checked for incontinence; rolled up the reusable incontinence pad from under the resident; rolled Resident R1 to her left side; removed the pillow from between Resident R1's legs; lifted Resident R1's legs and set them on a blue holder; went to Resident R1's closet, reached in, pulled out a clean incontinence brief; walked into Resident R1's bathroom and immediately walked out and went to Resident R1's bed; touched the end of the bed; lowered the head of the bed; placed a clean incontinence brief on Resident R1's bed; walked back to the bathroom; came back out; placed wipes on the bedside table; walked back to

the bathroom. walked back to the bedside table with a spray; grabbed the incontinence wipe and threw it on

the bed; lifted Resident R1's legs to adjust them; grabbed the wipe and cleaned Resident R1's perineal area; threw the dirty wipe down; grabbed a clean wipe; wiped Resident R1's perineal area; threw the wipe away; grabbed a clean wipe; grabbed paper towels and dried Resident R1's perineal area; adjusted Resident R1's legs and rolled resident over; removed soiled incontinence brief; grabbed a couple clean wipes and wiped Resident R1's buttocks several times; discarded dirty wipe; grabbed a clean wipe; dried Resident R1's buttocks again; discarded dirty wipe; grabbed paper towels and dried Resident R1's buttocks; discarded the paper towels; adjusted the incontinence pad; grabbed the new incontinent brief; tucked the brief under Resident R1; placed the new incontinence brief on Resident R1; removed blue foam pad from under Resident R1's legs and repositions Resident R1; adjusted pillows, blankets, and bed alarm; threw gloves in the trash; pulled out the old trash bag; put a new trash bag in the trash can and then V3 left Resident R1's room. On 10/9/25, at 11:05 a.m., V2/Director of Nursing would not confirm V3 should have changed gloves, from soiled body site to a clean body site, but rather the expectation is to perform hand hygiene for five minutes between dirty to clean surfaces. Per the Center for Disease Control/CDC, glove changes should occur when: If gloves become soiled with blood or body fluids after a task; If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs; If moving from care on one patient to another patient; and If they look dirty or have blood or body fluids on them after completing a task.

Event ID:

Facility ID:

If continuation sheet