Inspection·November 8, 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 perform COVID-19 testing on staff with direct high-risk exposure to a COVID-19 positive resident. The facility also failed to implement their COVID-19 Response Plan to monitor residents at least daily for a fever to prevent the potential spread of COVID-19 virus. These failures had the potential to affect the 15 residents residing on the facility ICF (Intermediate Care Facility East wing). Residents Affected - Some Findings include: The CDC's (Centers for Disease Control) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 5/8/23, documents, Nursing homes: Responding to a newly identified SARS-CoV-2-infected HCP or resident: When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP (Healthcare Professional) or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. The facility's COVID-19 Response Plan, dated 7/31/23, documents, Increased emphasis on early identification and implementation of source control whenever possible will be expected: Evaluate and manage residents with symptoms of respiratory infection. Ask residents to report if they feel feverish or have symptoms of respiratory infection. Activity monitor all residents upon admission and at least daily for fever and respiratory symptoms (shortness of breath, new or change in cough, and sore throat). On 11/6/23 at 8:15 a.m., the hallway entrance to the ICF (Intermediate Care Facility East wing) had a sign announcing that the ICF had COVID-19 positive residents and staff. The facility's COVID-19 Positive Timeline, provided by V1 (Administrator) on 11/6/23, documents that the facility's COVID-19 outbreak began when R1 tested positive for COVID-19 on 10/21/23. (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 3 Event ID: 145572 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 145572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Graham Hospital 210 West Walnut Street Canton, IL 61520 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)