Health inspection·February 15, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review, the Facility failed to ensure staff were wearing the appropriate Personal Protective Equipment (PPE) and following the required infection control practices. This has the potential to affect all 101 residents living in the Facility. Residents Affected - Many Findings include: On 2/13/24 at 7:35 AM, the front door of the Facility had a sign documenting a current COVID-19 outbreak status. The Facility's Undated Covid Dates Report documented there were 12 residents being isolated for COVID-19 on 2/13/24. The Facility's Undated Covid Dates Report documented R7 and R8 were being isolated for COVID-19 on 2/13/24. On 2/13/24 at 7:43, the door to R7's and R8's room was standing wide open, and there was no isolation supply cart outside the room. On 2/13/24 at 7:50 AM, V5 (Certified Nursing Assistant/CNA) was walking through dining room during breakfast service with her N-95 mask worn below her nose. She pulled the mask up over her nose and stated the Facility does require staff to wear masks during the outbreak, and she was going to get her eye shield right then. On 2/13/24 at 8:10 AM, there was a sign on R4's door documenting Enhanced Barrier Precautions which stated the requirement for gown, gloves, and mask. V8 (Housekeeper) donned gown and gloves and knocked on R4's door, then sprayed a rag for cleaning and entered the room with her face mask worn below her nose. V8 came out of R4's room with an empty meal tray and opened the meal cart in the hallway with the same gloves that had been worn in R4's room for cleaning. V8 deposited R4's dirty meal tray in the cart and returned to R4's room to resume cleaning with her mask remaining below her nose. On 2/13/24 at 8:14 AM, V9 (CNA) opened the meal cart with the handle V8 (Housekeeper) had just used, removed a tray, and delivered the tray to R6. On 2/13/24 at 8:15 AM, V7 (Licensed Practical Nurse), stated R4 has a wound infection. On 2/13/24 at 8:20 AM, V10 (CNA) was walking down the B Hallway wearing a mask that did not cover her nose. (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: 145571 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 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 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)