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. (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: 146047 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 146047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Village 1200 East Grant Street Macomb, IL 61455 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)