Health inspection·December 18, 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 follow its Covid-19 infection control policy and The State Agency guidelines on COVID-19 by having COVID-positive residents and asymptomatic/COVID-negative residents in the same room to prevent a potential outbreak. This applies to 4 of 8 residents (R1, R3, R5, and R7) reviewed in a sample of 9. Residents Affected - Some The findings include: R1 was a [AGE] year-old female admitted on [DATE] with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R2 (R1's roommate) is a [AGE] year-old female admitted on [DATE] with mild cognitive impairment as per MDS dated [DATE]. On 12/15/23 at 2:10 PM, R2 was observed in her wheelchair in her room and stated, I tested COVID-19 positive almost two weeks ago. I remain in my room with my roommate (R1). Record review on laboratory report dated 12/01/23 documented COVID-19 positive test result for R2. On 12/15/23 at 12:10 PM, V2 (Director of Nursing / DON) stated, R1 was exposed to COVID-19 as her roommate (R2) tested positive on 12/1/23. We could not move R1 from her roommate with COVID-19, who tested positive, as we had no private rooms available. So, we separated R1 and R2 in the same room by pulling the privacy curtain. R1 remained in the same room until she transferred to a local hospital on [DATE]. R3 is an [AGE] year-old female admitted on [DATE] with moderate cognitive impairment as per MDS dated [DATE]. R4 is a [AGE] year-old female admitted on [DATE] with moderate cognitive impairment as per MDS dated [DATE]. Record review on laboratory report result dated 12/13/23 (collected 12/11/23) indicates that R3 has a negative COVID result. Record review on laboratory report result dated 12/13/23 (collected 12/11/23) indicates that R4 has a positive COVID result. On 12/15/23 at 10:10 AM, observed R3 and R4 sharing a room. Page 1 of 2 145611 145611 12/18/2023 St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417

F 0880 Level of Harm - Minimal harm or potential for actual harm On 12/15/23 at 1:10 PM, V9 (Infection Preventionist) stated, We are not supposed to co-mingle positive and asymptomatic or exposed (PUI) residents together in the same room. We are doing it only because of the lack of private rooms.: On 12/15/23 at 10:20 AM, the surveyor observed R5 (wife) and R6 (husband) sharing a room. Residents Affected - Some A review of the progress note dated 12/4/23 documents that R6 tested COVID-19 positive on 12/4/23. Record review on laboratory report result dated 12/5/23 (collected 12/4/23) indicates that R5 has a negative COVID test result. On 12/16/23 at 1:15 PM, V2 stated, The family doesn't want to separate R5 and R6 even though R6 tested positive and R5 tested negative on 12/4/23. So, we keep them together. I don't have any documentation to prove the family preference to keep R5 and R6 together. Record review on laboratory report result dated 12/13/23 (collected 12/11/23) indicates that R5 tested positive for COVID. On 12/15/23 at 10:20 AM, observed R7 (Husband) and R8 (Wife) sharing a room. A review of the laboratory report result dated 12/5/23 (collected 12/4/23) documents that R8 tested COVID-19 positive on 12/4/23. Record review on laboratory report result dated 12/5/23 (collected 12/4/23) indicates that R7 has a negative COVID test result. On 12/16/23 at 1:18 PM, V2 stated, Again, the family doesn't want to separate R7 and R8. I don't have any documentation to prove the family preference to keep R7 and R8 together. Record review on laboratory report result dated 12/13/23 (collected 12/11/23) indicates that R7 tested positive for COVID. The facility presented the Coronavirus Disease (COVID-19) policy (Page 5) revised on 5/8/23 document the recommended infection prevention and control (IPC) practices when caring for a resident with suspected or confirmed SARS-CoV-2 infection document: The residents with symptoms of Covid-19 (even before the results of the diagnostic testing) and asymptomatic residents who have met the criteria for empiric Transmission-Based Precaution based on close contact with someone with SARS-CoV-2 infection should not be cohorted with residents with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. On 12/16/23 at 10:30 AM, V2 presented IDPH Updated Guidelines for Nursing Homes and stated that these are the most updated guidelines they follow through to care for COVID-19 residents. The State Agency guidelines (page 14) document: If limited single rooms are available or if numerous residents are simultaneously identified to have COVID-19 exposures or symptoms concerning COVID-19, residents should remain in their current location, draw a privacy curtain between beds, and wait for the test result. However, these residents should NOT be cohorted with residents with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. 145611 Page 2 of 2