Health inspection·June 27, 2025

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 the recommended guidelines to properly treat and disinfect a resident room with suspected bed bugs to prevent the spread of bed bugs for 2 of 3 residents (R1, R2) reviewed for infection control in the sample of 3. Residents Affected - Few The findings include: On 6/27/25 at 9:33 AM, R2 was in him room, sitting in his wheelchair. R2 said the staff reported bed bugs were found in this room on 6/23/25. R2 said they bagged his clothing this time on 6/24/25 (Tuesday) and he moved to another room and came back to his room on 6/26/25. On 6/27/25 at 9:47 AM, R1 was in his wheelchair out of his room on the computer in the lounge area. R1's hair was past his shoulder, long, scraggly, greasy and matted in the back. R1 had a long facial beard approximately 3 inches past his chin. R1 said on 6/23/25, the staff found a bed bug on his blanket near his leg. R1 said he stayed in his room until 6/26/25, when his room was sprayed by a pest exterminator. R1 said when they were treating his room, he was placed in the dining room for several hours. R1 said when he came out of his room on 6/26/25, he did not receive a shower. R1 said about a month ago, they found a bed bug, they took his clothes but left his roommate (R2's) clothes in his closet, this time they bagged both of their clothing. On 6/27/25 at 9:55 AM, R1's top dresser drawer had multiple items including, shirt, multiple pairs of socks, slipper socks, gauze wraps, knee brace, and toiletry items. A pair of shoes were in his armoire and wash bin of personal items located on top of the armoire. There were no items bagged in his room. R2 had personal items stored in drawer and wash bin of personal items on the top of his armoire. On 6/27/25 at 9:57 AM, V4 (Licensed Practical Nurse-LPN) said last month R1's room was being treated for bed bugs. At that time R1 and R2 could not leave the room, until they treated the room and went back to the same room after 3-4 hours. They did not remove all the clothing or items in the drawers at that time. We questioned if the proper treatment was done, but we were told the pest exterminator decides the type of treatment. It was frustrating clearly it was not done properly because another live bed bug was found on 6/23/25. On 6/23/25, staff reported they saw a bed bug on him. We were told the pest exterminator was supposed to come that day to treat the room, but they did not come until 6/26/25. R1 was isolated to his room, and they moved R2 to a different room. On 6/26/25, R1 was out in the common area while his room was being treated. He was supposed to get a shower before leaving his room but that did not happen. On 6/27/25 at 10:06 AM, V5 (Certified Nursing Assistant-CNA) said on 6/23/25, the staff found a bed Page 1 of 3 145801 145801 06/27/2025 Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bug on R1. R1's roommate (R2) refused to go back into that room, and we moved him to different room. R1 was placed on isolation. On 6/24/25, R2 was in the same clothes as the day before and she gave R2 a shower. R1's shower day is on Wednesdays, she worked on Monday, Tuesday and Friday this week. By looks of R1 he did not receive a shower this week. I'm not sure what they did to solve the problem with the bed bugs. She was told R1 should have received a shower before leaving him room. This is horrible for the residents and staff. On 6/27/25 at 1:09 PM, V6 (CNA) said she was R1's CNA on 6/25/25 and 6/26/25. She did not know R1's room had bed bugs; staff did not report anything to her. R1 told me the staff found a bed bug on his blanket on Monday 6/23/25. On 6/26/25, his room was sprayed, and she placed R1 in the dining room. She did not shower him before he left the room. No one educated us on what to do if bed bugs are found. V6 said R1's brother passed away and the family brought his clothing to him and his brother's home had bed bugs, she thinks that's where the bed bug came from. On 6/27/25 at 10:41 AM, V7 (Pest Exterminator) said if bed bugs are found all clothing should be bagged, removed, and laundered. All drawers should be emptied, and he recommends a decontamination room where the resident can go while the room is being treated. The day of treatment the resident should be cleaned before leaving the room. On 6/27/25 at 9:24 AM, V3 (Building Service Director) said about a month ago, R1's room was treated for bed bugs. On 6/23/25, another bed bug was found on R1. R1's room was treated yesterday, and we bagged and removed all of R1 and R2's clothing. V3 said they only bagged clothing and not personal items. V3 said he handles the environmental treatment of bed bugs and V2 (Director of Nursing) handles the clinical side of treatment. V3 said he did not keep a record of timing in May 2025 when bed bugs were found in R1's room. On 6/27/25 at 11:15 AM, V2 (DON) said if bed bugs are found residents should be isolated until the room is treated by the exterminator. Clothing should be bagged, removed, and washed. I don't understand why the resident should be showered before leaving their room. V2 said clothing may be potentially infected with bed bugs and that makes perfect sense. At 1:45 PM, V2 confirmed education was provided to staff on how to handle bed bugs, she was not familiar on the guidelines for treatment of bed bugs. V2 confirmed there was no documentation in R1 and R2's medical records regarding the treatment of bed bugs. R1's electronic health records for May to June 2025 does not show documentation of bed bugs found and the treatment provided. The facility provided a timeline on 6/27/25, it shows on 6/23/25, a bed bug was reported in room [ROOM NUMBER] and clothing items removed (there is no mention of bagging personal items) and 6/26/27 the room was treated. The facility's Treatment for Bed Bugs undated Policy states, Bed bugs can travel in clothing, bags, and can hide in small places, including under carpeting in drawers, light switches, electronic plugs, picture frames, padding, cervices, and screw holds in furniture, mattresses .cell phones, laptops, books. Bed bugs can live for over 1 year without feeding, so they can survive even if a room or apartment is not occupied .Suspected Steps to be taken if bed bugs are suspected or seen: contract with a professional pest control company that will treat the problem with an integrated pest management approach .all actions should be performed in the room to prevent the spread of bed bugs to other rooms. Assist the resident to showered, dress in clothing from the outside the room, including shoes, 145801 Page 2 of 3 145801 06/27/2025 Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350

F 0880 Level of Harm - Minimal harm or potential for actual harm socks and transfer to another room. Personal belongings, equipment and furnishings including beds should not leave the room until they have been thoroughly inspected and determined to be bed bug free .bag clothing in room in plastic bags, tie bag tightly. Wear PPE (personal protective equipment) including gown, and gloves. Bag everything in the closet, under the bed, in dresser drawers .Shoes and non-washable items should be bagged and left in the room for the professional pest control management. Residents Affected - Few 145801 Page 3 of 3