Health inspection·September 15, 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 report, track and perform COVID-19 testing of an employee that displayed COVID-19 like symptoms prior to providing services to 11 residents (R4 through R14) of 17 residents reviewed for COVID-19 in a sample of 14. Residents Affected - Some Findings include: The facility's Infection Surveillance - Employee policy dated 4/2023 documents Infection prevention begins with ongoing surveillance to identify infections that are causing, or have the potential to cause, an outbreak. The facility closely monitors all employees who exhibit signs/symptoms of infection through ongoing surveillance and has a systematic method for collecting, consolidating, and analyzing data concerning the frequency and cause of a given disease or event, followed by dissemination of that information to those who can improve the outcomes. The intent of surveillance is to identify possible communicable diseases or infections before they can spread to other persons in the facility. In addition, surveillance is crucial in the identification of possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. The results should be used to plan infection control activities, direct in? service education, and identify individual resident problems in need of intervention The outcome surveillance process consists of collecting/documenting data on individual cases and comparing the collected data to standard written definitions (criteria) of infections. The Infection Preventionist, department supervisor or other designated staff record reports of symptoms on the Employee Infection List/Log and/or other diagnostic test results consistent with potential infections to detect clusters and trends and to be able to identify and report evidence of a suspected or confirmed HAI (Healthcare-Associated Infection) or communicable disease. Sources of relevant data that can be used for outcome surveillance for infections and susceptibility may include: Reporting of fever or signs that may indicate an infection. Reporting of illness; including symptoms. Reporting of diagnostic test results consistent with potential infections to detect clusters, trends, or susceptibility patterns. R5's medical record dated 8/26/23 documents Resident's daughter called back, and requested a COVID test, reporting that her mother generally does not run fevers with UTIs (Urinary Tract Infection). (V2, Director of Nursing (DON)) was on the unit and a rapid swab was obtained. COVID swab was positive. R4, and R6's medical record documents they tested positive for COVID-19 on 8/26/23. R7 through R14's medical record documents they all tested positive for COVID-19 on 8/28/23. The facility's employee COVID-19 tracking sheet documents V7, Cook, tested positive for COVID-19 on 8/25/23. Page 1 of 2 146047 146047 09/15/2023 Wesley Village 1200 East Grant Street Macomb, IL 61455

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility's August 2023 employee infection surveillance tracking log does not document V7's, Cook, symptoms of COVID-19 prior to 8/25/23. The facility's dietary schedule dated 8/24/23 documents V7, Cook, worked on the memory care unit. On 9/14/23 at 10:05 AM, V3, Certified Nursing Assistant (CNA) stated I can't speak to what other employees do, but if we have symptoms of COVID, were supposed to notify the nurse prior to coming into the building and they come out, test us for COVID and take our temperature. If we're cleared, we can work, but we have to test every day if symptomatic. Like right now I have stuffiness, but I test every day prior to coming in and have to have my temp checked. On 9/14/23 at 10:17 AM, V6, Registered Nurse (RN) stated The employees are supposed to notify us before coming into the building if they have symptoms. If they do come in, we immediately send them out to their car. We go out to their car, perform a COVID test, take their temperature and then document their symptoms. If they're negative, we contact the on call, DON (Director of Nursing) or the administrator to find out if they're cleared to come in to work. If they're positive, they have to go home, and we still have to contact the DON and administrator to let them know there's a positive employee. On 9/10/23 at 10:50 AM, V7, Cook, observed in the kitchen on the memory care unit preparing resident meals. V7, [NAME] stated I came to work on Tuesday (8/22) with a sore throat. I didn't think much of it because that happens. I'll have a sore throat in the morning, but then it goes away. When I got home, I tested for COVID, and it was negative. The next day (8/23) I was still sick, so I went to clinic and tested, and it was negative. On Friday (8/24) I came to work with a stuffy nose, sore throat and my ears were popping. I didn't test before coming into work. No, I didn't report my symptoms to anyone, but they kind of knew. I sounded like a frog. The next day (8/25/23) I tested at home and was positive and notified my supervisor. I did not report my symptoms on 8/22 or 8/24 to the facility. On 9/14/23 at 10:57 AM, V2, DON, stated Anytime an employee is sick, they have to call from the parking lot and inform the nurse they're symptomatic and the nurse will go out, take their temperature and give them a COVID test. They are not to be in the building working with symptoms unless cleared by one of the nursing supervisors. They are required to report symptoms prior to working. I was not aware that (V7, Cook) came to work sick without testing, she should have tested prior to working. On 9/14/23 at 12:38 PM, V2, DON stated (R5) was the first one to test positive on 8/26. We then tested everyone on the unit and her roommate (R6) and (R4) tested positive, but no one at that point. We do days one, three and five for testing and on day three of the testing the rest of the unit tested positive. 146047 Page 2 of 2