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 ensure staff were following the
proper PPE (Personal Protective Equipment) protocols for residents in isolation. This has the potential to
affect all 59 residents living in the facility.
Residents Affected - Many
The findings include:
On 10/4/23 at 8:45am, V1 (Administrator) said that they had 27 positive COVID residents, 16 exposures
and 14 staff that tested positive also. V1 said that the first positive case was a staff member on 9/22/23 and
the last positive case was on 10/3/23. V1 said that each resident was placed on droplet precautions and
signs posted on the door.
1. On 10/4/23 at 10:00am, Observations were made of signage outside of R4's door indicating the
sequence for putting on personal protective equipment (PPE) noting: 1. gown. 2. mask or respirator 3.
goggles or face shield 4. gloves.
On 10/4/23 at 10:00am, V5 (CNA/Certified Nurse Assistant) was observed in R4's room pulling R4
backwards through the door. V5 was wearing a N95 mask and gloves. V5 was not wearing a face shield or
a gown. R4 was not wearing a mask.
On 10/4/23 at 10:00am, V5 said she needed her glasses to see what PPE she needed to wear. V5 also
said she had been in-serviced on what PPE to wear for droplet precautions.
R4's document labeled point of care testing results document that R4 tested positive for COVID-19 on
10/1/23,
2. On 10/4/23 at 10:40am, Observations were made of signage outside of R5's door indicating the
sequence for putting on personal protective equipment (PPE) noting: 1. gown. 2. mask or respirator 3.
goggles or face shield 4. gloves.
On 10/4/23 at 10:40am, V5 (CNA) was observed in R5's room. V5 was wearing a N95 mask and gloves. V5
was not wearing a gown or eye shield. V5 was providing resident care and there was a food tray sitting
outside of R5's room on the floor. V5 was told by V2 (MDS/Care plan Coordinator) to put on a gown and
face shield. V2 also brought a trash bag to bag the tray and take to the kitchen.
Document labeled Residents note that R5 was on isolation due to COVID-19 exposure on 10/3/23.
3. On 10/4/23 at 10:20am, V11 (COTA/Certified Occupational Therapist) was observed in the hallway only
wearing a N95 mask. V11 was not wearing a face shield. V11 (COTA/Certified Occupational
(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:
146006
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
146006
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Integrity Hc of Anna
315 South Brady Mill Road
Anna, IL 62906
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)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Therapist Assistant) said she was not aware of what PPE to wear and did not know you had to wear
goggles and then returned to the therapy room.
On 10/5/23 at 2:00pm, V1 said she has provided in-services to staff many times on the PPE and they
should know. V4 said there is also signs posted outside each resident that is positive COVID that tells staff
what they need to wear.
Facility Policy labeled Visitation and Infection Control Policy reviewed 2020, note in general, for care of
residents with undiagnosed respiratory symptoms and/or infection use standard, contact and droplet
precautions with eye protection, unless suspected diagnosis requires airborne precautions (e.g
tuberculosis). The same policy note to post signs on the door or outside of the resident room that clearly
describe the type of precautions needed and required PPE.
The Resident List Report dated 10/4/23 documents the facility had a census of 59 residents.
On 10/4/23 at 10:20am, V11 (COTA/Certified Occupational Therapist) was observed in the hallway only
wearing a N95 mask. V11 was not wearing a face shield. V11 (COTA/Certified Occupational Therapist
Assistant) said she was not aware of what PPE to wear and did not know you had to wear goggles and
then returned to the therapy room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146006
If continuation sheet
Page 2 of 2
