Health inspection·February 26, 2025

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 ensure staff wore the correct personal protective equipment (PPE) and failed to complete handwashing prior to leaving residents' rooms on contact isolation for norovirus while the facility is in outbreak status. This applies to 2 of 26 (R1, R2) residents reviewed for infection control. Residents Affected - Few The findings include: On 2/26/2025 at 9:13AM, R1's room had a contact isolation sign posted clearly on the door frame. V5 (Certified Nursing Assistant/CNA) was observed moving R1 into her room in a chair. V5 moved R1 up next to the resident's bed and began rearranging the resident's pillow and pad on the bed. V5 did not have a gown or gloves on. When V5 exited R1's room she did not wash her hands. V5 stated R1 was on contact isolation for exposure to norovirus. V5 stated you need a gown and gloves when entering a contact isolation room. V5 said hand washing is required for residents suspected of having norovirus. V5 said she did not wash her hands because she did not touch a resident. On 2/26/2025 at 9:22AM, the isolation cart in the hallway with R1 and R2 was about two rooms away filled with gowns, gloves, masks, and bleach wipes. On 2/26/2025 at 9:51AM, V6 (Assistant Director of Nursing/ADON) said residents having norovirus symptoms are placed on isolation and it doesn't end until they are symptom free for 48 hours. V6 said hand sanitizer is ineffective for norovirus and staff must wash their hands. On 2/26/2025 at 10:04AM, V2 (Director of Nursing/Infection Control Preventionist) said R1 and R2 are currently roommates because they are having the same symptoms of nausea or vomiting, and diarrhea. V2 said contact isolation requires the staff to wear gown, gloves, and handwashing in required for norovirus. V2 said staff should apply gown and gloves before entering a resident's room and wash their hands prior to leaving the resident's room. On 2/26/2025 at 12:03PM, V8 (Health Department Infection Disease Coordinator) stated she would consider the facility in outbreak status as of 2/21/2025 based on the line list the facility provided to her on 2/24/2025. On 2/26/2025 at 12:30PM, V8 (Hospice Social Worker) was observed in R1 and R2's room talking to R1. V8 did not have a gown or gloves on in the resident's room. V8 exited R1's room without washing her hands. V8 said she did not know why the residents in that room were on isolation and she was only at the facility to see R1. V8 was seen using hand sanitizer in the hallway, but no hand washing was observed. (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 2 Event ID: 145200 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 145200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franklin Grove Living and Rehab 502 North State Street Franklin Grove, IL 61031 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)