Health 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 Page 1 of 2 145519 145519 09/06/2023 Evervella of White Hall 620 West Bridgeport White Hall, IL 62092

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many threshold levels that would prompt additional investigating or enhanced control measures. 7. The identification of a single COVID-19 positive resident or staff triggers an outbreak investigation . Control Measures: 1. Any resident suspected of having coronavirus will be placed on standard, contact and droplet precautions as per CDC guidelines. The timeframe for precautions [NAME] be determined on a case-by-case basis. Such a decision will take into account the severity of the illness, comorbid conditions, resolution of fever and clinical status of resident . 5. While on transmission base precautions, residents are to be confined to their room as much as possible and should not attend communal activities/dining. 6. Personal protective equipment (PE) including gloves, gown, ace mask or respirator are to be utilized for any healthcare worker entering the resident's room for suspected or confirmed cases . Visitation: Signage is to be posted throughout the facility including entrances, regarding reporting symptoms of or exposure to someone with COVID and refraining from visiting if ill . Preventing Illness: 3. the CDC recommends the following core principles of infection prevention to help prevent the spread of respiratory diseases, including: perform hand hygiene before applying and removing PPE, including gloves . Avoid contact with people who are symptomatic. For residents suspected or with coronavirus, close contact includes being approximately 6 feet of the residents for prolonged periods of time or having direct contact with the resident infectious secretions .Testing Frequency: Follow instructions below for prioritization of testing: Asymptomatic health care provider (HCP) not wearing Personal Protective Equipment (PPE) that are exposed testing is recommended as soon as possible (but generally not earlier than 24 hours after exposure if known) on days 1, 3, and 5 unless recovered from Covid in the past 30 days . Newly identified COVID-19 positive staff or resident in a facility that can identify close contacts- test all staff and residents on the affected unit (s), vaccinated and unvaccinated , that had high risk exposure with a COVID-19 positive individual. Testing is recommended as soon as possible (but generally not earlier than 24 hours after exposure if known) on days 1, 3, and 5 A new COVID-19 infection in any staff or any nursing home onset resident triggers an outbreak investigation .Asymptomatic with close contact who do not consistently wear mask or are immunocompromised, or reside near other who are severely immunocompromised or reside on a unit with ongoing COVID transmission, place in TBP (transmission based precautions) for 7 days ( count day of exposure as day 0) and negative test, test on days 1, 3, and 5. Discontinue TBP if negative. TBP for 10 days if no negative test, exposure day = day zero (0). 145519 Page 2 of 2