Health inspection·March 20, 2024

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 infection control guidelines provided by IDPH (Illinois Department of Public Health) after a resident tested positive for Legionnaire's Disease. The facility's policy for Legionnaire's Disease was also incorrect according to CDC (Centers for Disease Control and Prevention) guidelines. The facility also failed to ensure staff wore appropriate PPE (Personal Protective Equipment) in a COVID-19 positive resident's room. Residents Affected - Few This applies to 2 of 4 residents (R3, R4) reviewed for infection control in the sample of 4. The findings include: 1. On March 14, 2024 at 10:36 AM, V24 (IDPH Environmental Health) said she had sent the facility an email on March 7, 2024 to notify them of a positive case of Legionnaire's Disease for a resident (R1) who had resided in the facility prior to hospitalization. V24 said the email included instruction for the facility to restrict all water use or install a 0.2-micron biological filter to the faucet in the room where R1 stayed in. V24 said she did an on-site visit at the facility on March 11, 2024. V24 said during the visit, she told the facility the toilet in R1's room could be used, but an alternative measure for handwashing needed to be in place. At 11:56 AM, V24 said the water in the handwashing sink could not be used until the sample results came back because handwashing could still create aerosolized water. On March 13, 2024 at 2:38 PM, R2 (R1's roommate from February 17, 2024 to February 28, 2024) and R3 (R2's roommate from March 1, 2024 to present) had a sign on their bathroom mirror saying, This sink is for handwashing only. Please use bottled water for anything else including drinking. Thank you! At 2:38 PM, R3 said he used the toilet and washed his hands in the bathroom. On March 14, 2024 at 10:56 AM, R2 and R3's bathroom mirror had the same sign posted. R3 said he used the bathroom in the morning and washed his hands in the sink. On March 14, 2024 at 11:24 AM, V15 (Director of Maintenance) said none of the faucets had 0.2-micron biological point-of-use filters. V15 said there was no filters in any of the faucets. V15 said they had not applied the filters because they only needed to apply the filters if the tests came back positive for legionella. On March 14, 2024 at 11:19 AM, V1 said the email from V24 showed to install new filters or to restrict the use, so the facility was using the sink only for handwashing. R3's face sheet showed R3 was admitted to the facility with diagnoses including emphysema, chronic obstructive pulmonary disease, pneumonitis, pleural effusion, weakness, and need for assistance with Page 1 of 2 145899 145899 03/20/2024 Warren Barr Orland Park 14601 South John Humphrey Dr Orland Park, IL 60462

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few personal care. R3's Minimum Data Set (MDS), dated [DATE] showed R3 was cognitively intact. R3 required substantial assistance with toileting hygiene and shower/bathing. The CDC's March 25, 2021 Legionella Things to Consider: Healthcare-associated Cases and Outbreaks guidelines showed Examples of immediate control measures include: Restricting showers (using sponge baths instead) .Avoiding use of water from sink/tub faucets in patient rooms to avoid creating aerosols .Installing point-of-use ([NAME]) microbial filters with an effected pore size of 0.2 microns or less .Correct location selection is critical to Legionella exposure prevention across the water system. 2. R4's face sheet shows R4 was admitted to the facility with diagnoses including COVID-19, metabolic encephalopathy, dementia, pneumonitis, and interstitial pulmonary diseases. R4 was newly admitted to the facility and the MDS was incomplete. On March 13, 2024 at 10:15 AM, R4's room had a droplet and contact isolation sign on the doorway. V6 (Restorative Aide) was in R4's room without a face shield on. At 10:18 AM, V6 came out of R4's room and said R4 was positive for COVID-19. V6 said she had an N-95, the gown, and gloves on. On March 14, 2024 at 2:25 PM, V20 (CNA/Certified Nurse Assistant) said for a resident on COVID-19 isolation guidelines, the staff should wear a gown, gloves, N95 face mask, and a face shield. V20 said if they do not wear all the PPE, it's possible to catch COVID-19. On March 14, 2024 at 2:31 PM, V28 (CNA) said R4 was on isolation for COVID-19. V28 said the staff need to wear a gown, N95, face shield, and gloves in her room. On March 14, 2024 at 2:34 PM, V29 (LPN/Licensed Practical Nurse) said the staff should wear a gown, gloves, an N95 mask, and goggles. V29 said the staff could get exposed to the virus if they do not wear the appropriate PPE. On March 14, 2024 at 2:42 PM, V2 (DON/Director of Nursing) said the staff are supposed to wear a gown, gloves, N-95 face mask, and a face shield in the COVID-19 positive rooms. V2 said the staff are supposed to wear all the PPE going into the isolation rooms. V2 said it can cause the staff to be exposed or expose the other residents to the virus. The facility's undated Basic PPE and COVID Guidance showed to Use N95 and Face shield plus Gown and Gloves when caring for residents on quarantine or isolation. 145899 Page 2 of 2