Inspection·September 6, 2023

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 observation, interview, and record review, the facility failed to implement broad based testing or contact tracing and implement infection control to prevent the spread of COVID infection. This has the potential to affect all 103 residents at the facility. Residents Affected - Many Findings include: 1. On 8/29/2023 at 7:29 AM, V10 (Licensed Practical Nurse/LPN) was passing meds on the rapid recovery unit with Covid positive residents. V10's surgical mask was on under her nose. 2. On 8/30/2023 at 9:32AM, V2 (Interim Director of Nursing/DON) stated V19 (LPN) had called her on morning of August 9th, and told her she was positive for COVID. V2 stated V19 worked the rapid recovery unit on 8/6/2023. V19's time sheet documents V19 clocked in at 6:25AM and clocked out at 7:16PM on 8/5 and 8/6/2023, working 12 hours from 6:30am- 7:15 pm on both days V2 stated there was no contact tracing done at that time. V2 stated, If someone had symptoms we would test. (R1) was having psych issues and was sent to local hospital for evaluation and tested positive there for Covid. (R1) resided on the rapid recovery unit. 3. On 8/30/2023 at 10:55AM, Memory unit lunch carts were being passed by staff; 2 family members were sitting at a table with their family with surgical masks on. Surveyor asked V4, Activities, if R9 was in the dining room eating, and V4 pointed him, R9, out at the table, who was sitting with 5 other table mates. R9 was positive for Covid. V4 stated V4 did not know why he was at the table. R9 was sitting at the table in the dining area with tablemates R10, R11, R12, R13 and R14. R15 and R16 had family members present in the dining area with surgical masks on. The facility Outbreak summary, dated August 2023, documents as of 9/2/2023, 26 residents have tested positive for Covid, and 13 staff, tested positive for Covid-19, with R1 being the first case. The outbreak summary documents R1 tested positive on 8/17/2023, during emergency room visit at the local hospital. The facility census list dated 8/28/2023 documents, a census of 103. On 9/5/2023 at 9:15AM, V3 (Director of Nursing/DON) stated she would expect staff to follow infection control and follow facility policy. The facility's Coronavirus (COVID-19) policy, dated 6/23, documents in part, Surveillance: 2. monitoring and testing of any current resident or staff member exhibiting signs or symptoms. 3.Monitoring coronavirus in the facility by the infection preventionist. This data will be utilized define (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: 145519 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 145519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of White Hall 620 West Bridgeport White Hall, IL 62092 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)