Health inspection·July 17, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review, the facility failed to cohort residents with the same infectious conditions and follow infection control protocol for COVID-19. This has the potential to affect all 112 residents in the facility. Residents Affected - Many Findings Include: 1.The Facility's Infection Surveillance Monthly Report, dated 7/16/24, documents R5 and R6 were both positive for Covid-19 on 7/6/24. The July Infection Surveillance report documents there are 48 residents in the facility with Covid-19 infection. On 7/16/2024 at 9:00 AM, V10, OT (Occupational Therapist), was in R5 and R6's room with a N95 mask intact, no other PPE noted. V10 stated she thought they (R5 & R6) were off (isolation) today. Contact/droplet precautions signage was on the R5's and R6's door of the room they were residing in. On 7/16/24 At 10:00 AM on 500 Hall, isolation carts were on the hall. V8, CNA (Certified Nursing Assistant) was on the hall with N95 mask intact. V8 stated, Gowns, gloves, and masks are placed on when in the resident's room, providing care. We do have some residents that are positive for COVID on the hall. On 7/16/2024 at 9:05 AM, V5, Licensed Practical Nurse/LPN, stated the signs on the doors indicative of positive COVID residents, she stated, Yes they are on isolation for COVID. Everyone has to be in full PPE ( gloves, mask, face shields, and gown). On 7/16/24 at 9:25 AM, V6, Housekeeper, stated she wears gowns, gloves, N95 mask when cleaning the rooms. V6 is unaware of face shields to be worn. On 7/16/24 at 1:00 PM, V17, Computer/Internet technician, stated, I did not know that they had COVID, and I didn't know I should be wearing a mask. I probably should have. V17 stated he will put one on when he comes back into the building. On 7/16/24 at 1:39 PM, V4, LPN/Infection Control Preventionist, stated she expected the staff to be wearing gowns, gloves, mask, and face shields. V4 stated the nursing staff do not like to wear the goggles/eyewear. 2. R3's Physician Order Sheet, dated 7/9/24, documents strict contact/droplet isolation related to COVID until 7/20/24 all services rendered in room. R4's Labs Results Report, dated 7/11/24, documents R4 was negative for COVID19. (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 3 Event ID: 145717 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 145717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nexus at Columbia 253 Bradington Drive Columbia, IL 62236 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)