Health 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. Page 1 of 3 145572 145572 11/08/2023 Graham Hospital 210 West Walnut Street Canton, IL 61520

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility Nursing Monthly Schedule, dated 9/24-10/21/23, documents that for 48 hours prior to R1's COVID-19 positive test the following staff members took care of R1 and would have had direct exposure to her: V4 (RN-Registered Nurse), V5 (RN), V6 (RN), V7 (CNA-Certified Nursing Assistant), V8 (CNA), V9 (CNA), V10 (CNA), V11 (CNA), V12 (CNA), V13 (CNA), and V14 (RN). The facility ICF COVID-19 testing, provided on 11/6/23 by V3 (Infection Preventionist), documents that following R1's COVID-19 positive test on 10/21/23, the facility began testing staff who work on ICF and the residents who reside on ICF on 10/22/23. The testing also documents that following the facility's initial testing, testing was not done again for a week (10/30/23). R2's (R1's Roommate) Electronic vitals, dated 10/21-10/25/23, have no documentation of R2's temperature being checked during the timespan following R2's direct high-risk exposure to R1 while R1 was COVID-19 positive. R2's Discharge summary, dated [DATE], documents, She tested positive for COVID-19 with minimal symptoms. Per hospital policy she needs airborne isolation. R3's electronic vitals, dated 10/21/23 to 11/6/23, document that R3's temperature was only obtained on the follow dates, during the facility outbreak, 10/24/23, 10/31/23, and 11/2/23. R4's Electronic Vitals, dated 10/21-11/6/23, document that R4's temperature was only obtained on the following dates, during the facility outbreak, 10/25/23, 11/1/23, 11/2/23, and 11/3/23. R5's Electronic Vitals, dated 10/21-11/6/23, document that R5's temperature was only obtained on the following dates, during the facility outbreak, 10/24/23, 11/1/23, and 11/6/23. On 11/6/23 8:20 a.m., V14 stated, We are tested weekly on Mondays. When (R1) tested positive (10/21/23), we were all tested that following Monday then weekly after that. V14 confirmed that he was directly exposed to R1, and he was not tested on day one, day three, and day five following his COVID-19 exposure to R1. On 11/6/23 at 11:00 a.m., V2 (Director of Nursing) stated, We started testing residents and staff the day after (R1) tested positive, and then we went to weekly. On 11/8/23 at 9:47 a.m., V11 stated, Since the outbreak has started, I've been tested a total of three times. I tested the Tuesday (10/24/23) after (R1) tested positive, and then weekly after that. On 11/6/23 at 2:10 p.m., V1 stated, Residents should be monitored for symptoms of COVID at least once a day, and with that they should be checking the resident's temperature. V1 confirmed that R2, R3, R4, and R5's temperatures were not being monitored on a daily basis. On 11/6/23 at 2:15 p.m., V3 stated, When (R1) tested positive (10/21/23) we started the immediate testing of all the residents and staff who may have had direct exposure to her in the last 48 hours. We tested within 24 hours. Then, on 10/25/23 (R2) tested positive because she was having symptoms. Once she tested positive, we started testing all the residents and the staff in that unit (ICF) weekly. We did not do the initial day 1, day 3, day 5 testing on those staff and residents who had direct exposure to (R1) initially. We didn't think we had to do that because we do PCR (Polymerase Chain Reaction COVID-19) testing and not antigen testing. All residents should be monitored for COVID-19 symptoms on a minimum of a daily basis, and that includes temperatures. 145572 Page 2 of 3 145572 11/08/2023 Graham Hospital 210 West Walnut Street Canton, IL 61520

F 0880 The facility's ICF Daily Census, dated 11/6/23, documents that 15 residents (R1-R15) reside on this wing of the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 145572 Page 3 of 3