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 (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: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Orland Park 14601 South John Humphrey Dr Orland Park, IL 60462 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)