Health inspection·September 23, 2024

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 implement infection control measures to prevent the spread of COVID-19 (Human Coronavirus Infection) by failing to stock isolation carts with N95 masks, ensure isolation signage was posted, and ensure staff discarded personal protective equipment (PPE) upon leaving COVID-19 positive resident rooms. The facility also failed to complete COVID-19 symptom monitoring for residents having COVID-19. These failures affect five (R1, R2, R4, R5, R6) of six residents reviewed for infection control in the sample list of eight. Residents Affected - Some Findings include: The facility's COVID-19 Testing and Response Plan dated 9/1/24 documents monitor for clinical worsening including assessing for symptoms and vital signs for every four hours for COVID-19. This policy documents to discard respirator or mask and a new one should be applied after caring for a COVID-19 positive resident. The facility's General Approaches to Infection Prevention and Control Standard and Transmission-Based Precautions for Communicable Disease policy dated 10/17/22 documents to post isolation signage on the door or wall outside of the residen'ts room and make sure all PPE is readily available. 1.) On 9/19/24 at 9:40 AM and at 11:09 AM R1's room door was open and there was no isolation signage posted on R1's room door or wall. R1 and R5 shared the same room. The PPE cart outside of R1's room did not contain a supply of N95 masks. At 12:46 PM there was no isolation signage posted outside of R1's room. On 9/19/24 at 9:46 AM V5 Certified Nursing Assistant (CNA) was working on R1's unit, the South Pod, wearing an N95 mask. V5 stated R1 is the only COVID-19 positive resident on the unit. On 9/19/24 at 10:24 AM V7 (Housekeeper) was working on R1's unit. V7 stated V7 was unsure which residents on the South Pod were COVID-19 positive and the COVID-19 rooms are identified with contact/droplet isolation signage. On 9/19/24 at 11:23 AM V5 CNA was wearing an N95 mask and donned gown, gloves eye protection to enter R1's room. V5 provided incontinence cares for R1. At 11:30 AM V5 left R1's room and did not change V5's N95 mask. At 11:33 AM V5 confirmed V5 did not change her N95 worn in R1's room and confirmed the PPE cart outside of R1's room did not contain N95 masks. V5 stated V5 was unsure if N95 masks are suppose to be changed when leaving positive resident rooms, and V5 has not been changing her mask when leaving positive resident rooms. V5 stated there should be a supply of N95 masks in the PPE carts if they expect us to change them when leaving the rooms. V5 stated V5 was told in report that R1 tested positive and she was working the day R1 tested positive. V5 stated R1 didn't have an Page 1 of 2 145708 145708 09/23/2024 Country Health 2304 C R 3000 N Gifford, IL 61847

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some isolation sign posted yesterday and confirmed there is no sign posted today. V5 stated R1 is suppose to have an isolation sign posted and R5's daughter visits frequently who would also need to know of isolation precautions. At 11:39 AM V5 answered R4's call light and then R2's/R6's call light while wearing the same N95 mask worn in R1's room. These rooms were not COVID-19 positive rooms. On 9/19/24 at 12:50 PM V9 (Licensed Practical Nurse) stated R1 is the only COVID-19 positive resident on the unit. V9 stated V9 changes her N95 mask each time she leaves a COVID-19 positive room, but V9 has to leave R1's unit to get a new N95 mask from the South Hall since there isn't a supply of N95 masks in R1's PPE cart. V9 stated vital signs are taken daily for exposed and positive residents. R1's ongoing Diagnosis List documents R1 has diagnoses of Congestive Heart Failure, Emphysema, Atrial Fibrillation, and Type Two Diabetes Mellitus. R1's Nursing Note dated 9/17/2024 at 9:35 AM documents R1 was refusing to eat and had congestion, nasal drainage, and fatigue; R1 was tested and R1 tested positive for COVID-19. There are no documented symptom monitoring or respiratory assessments documented in R1's medical record after this note. R1's Physician Orders dated 9/17/24 document Contact/Droplet Isolation related to COVID-19 and obtain vital signs twice daily for 10 days. There is no documentation that R1's vital signs are monitored every four hours after testing positive. On 9/19/24 at 1: 04 PM V3 Infection Preventionist stated staff should apply gown, gloves, eye protection, and N95 masks when going into COVID-19 positive rooms and all PPE discarded when leaving the room. V3 confirmed isolation PPE carts should contain a supply of N95 masks. V3 stated contact/droplet isolation signs should be posted for COVID-19 positive rooms. V3 stated we are following doctor's orders for vital signs and symptom monitoring to be completed twice daily, and this should be documented in nursing notes, vitals section, or Medication/Treatment Administration Record. At 2:25 PM V3 stated after reviewing the facility's policy, COVID-19 positive residents should have vital signs and symptom monitoring every four hours. V3 confirmed R1's medical record does not document symptom monitoring and vital signs every four hours. 145708 Page 2 of 2