Health inspection·January 20, 2026

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and wore and/or changed personal protective equipment (PPE) in a manner to prevent potential exposure to and transmission of contagious diseases. These failures have the potential to affect all 151 residents living in the facility.The findings include:The facility's Facility Data Sheet dated 1/20/26 shows their current census is 151.The facility's 1st Floor Census sheet dated 1/20/26 shows R2, R3, and R4 are each positive for COVID-19.The facility's Isolation Tracking sheet dated 1/19/26 shows R2 tested positive for COVID-19 on 1/14/26, R3 tested positive for COVID-19 on 1/17/26 and R4 tested positive for COVID-19 on 1/16/26. They were each placed on contact/droplet isolation on the day they tested positive.On 1/20/26 at 10:40 AM, V10, Certified Nursing Assistant (CNA), went to R2's room wearing a surgical mask. V10 then put a N95 mask over the surgical mask along with other PPE (gloves, face shield, and gown) and entered R2's room. R2's room was marked with a sign for N95 Plus Eye Protection and Contact Precautions.On 1/20/26 at 10:50 AM, V8, Physical Therapy Assistant (PTA) exited R3's room wearing a surgical mask over an N95 mask, he did not remove either mask and did not use hand sanitizer outside the room. On 1/20/26 at 10:52 AM, V8, wearing the same masks, went to R4's room. V8 said he is doing in room therapy with the COVID-19 positive residents. V8 said he knows what/if a resident is on isolation by looking at the sign on their door outside their room. R4's room was marked with a sign for N95 Plus Eye Protection and Contact Precautions. V8 said he can go to Covid rooms wearing the same N95 mask, then entered R4's room.On 1/20/26 at 10:51 AM, V10 went to R3's room which was marked with a sign for N95 Plus Eye Protection and Contact Precautions. V10 placed an N95 mask over her surgical mask (along with other required PPE), then entered R3's room.On 1/20/26 at 11:11 AM, V4 Infection Prevention Nurse, said residents with COVID-19 are placed on Contact/Droplet Isolation. The signs outside their rooms indicate the PPE to be worn in the rooms at all times. The required PPE for the Contact/Droplet Isolation rooms includes a gown, gloves, eye protection, and an N95 mask. V4 said N95 masks are to be changed after leaving every room, all PPE is thrown away and new PPE is donned before going into the next room. V4 said the N95 mask is fit tested to be worn and fitted to the person; a surgical mask with an N95 over it is not appropriate. V4 said it would not be effective coverage to protect against COVID-19 or influenza. V4 said hand hygiene needs to be done before entering and after leaving each resident room.On 1/20/26 at 1:46 PM, V4 said they try to keep staff in same unit, but they may have to work on other units.On 1/20/26 at 1:50 PM, V5, Director of Rehab, said staff wear an N95 mask, gowns, gloves, and eye protection/face shield when seeing COVID-19 residents. Staff must change all of their PPE and use hand sanitizer between residents. V5 said she tries to have the same staff see Covid patients to minimize exposure, but assignments may change daily.On 1/20/26 at 1:58 PM, V11, Regional Nurse, said they educate staff on donning/doffing PPE using the isolation poster. V11 said the isolation for COVID-19 is contact/droplet precautions.The facility's Infection Prevention and Control Policy (revised 2/10/25) shows hand hygiene will be performed by staff Residents Affected - Many Page 1 of 2 145706 145706 01/20/2026 Whitehall of Deerfield 300 Waukegan Road Deerfield, IL 60015

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many before and after direct patient contact and after each situation that necessitates hand hygiene.The facility's Infectious Diseases Isolation Guideline & Care Policy (updated 2/13/25) shows residents with COVID-19 are placed on contact, droplet, N95 precautions for 10 to 20 days depending on the degree of illness.The facility's N95 Plus Eye Protection and Contact Precautions sign (poster) (dated 1/25) shows everyone must clean their hands, including before entering and when leaving the room, put on a fit-tested N-95 respiratory mask before room entry, and remove it after exiting the room. 145706 Page 2 of 2