Health inspection·October 10, 2023

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 Page 1 of 2 146006 146006 10/10/2023 Integrity Hc of Anna 315 South Brady Mill Road Anna, IL 62906

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. 146006 Page 2 of 2