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 (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 2 Event ID: 145708 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 145708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Health 2304 C R 3000 N Gifford, IL 61847 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)