Inspection·February 11, 2025

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 wore the required personal protective equipment (PPE) when entering residents' rooms that were on isolation for influenza. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for infection control in the sample of 3. Residents Affected - Few The findings include: 1. R1's Face Sheet printed on 2/11/25 showed R1 was diagnosed with influenza on 2/3/25. R1's Order Summary Report printed on 2/11/25 showed an order for R1 to be on droplet isolation for influenza dated 2/5/25 with no end date. A second order for droplet isolation with a start date of 2/11/25. On 2/11/25 at 8:31 AM, on R1's door was a sign indicating R1 was on enhanced barrier precautions. There was no sign up indicating R1 was on droplet/contact isolation. V9 (Activity Aide) was in R1's room. V9 had on a surgical mask and no other PPE. V9 was within 6 feet of R1. On 2/11/25 at 8:50 AM, V3 (Certified Nursing Assistant - CNA) was outside of R1's room placing a droplet/contact isolation sign on R1's door. On 2/11/25 at 9:15 AM, V3 said there was some confusion if R1 was still on droplet/contact isolation. V3 said R1 was to be on droplet/contact isolation for influenza. R1's progress note entered by V10 (Infection Control Nurse) dated 2/11/24 at 2:23 AM, showed R1 had a recent fever with worsening symptoms and was to remain on isolation. On 2/11/25 at 11:35 AM, V2 (Director of Nursing) said R1 was to be on droplet/contact isolation for influenza as they wait for clarification if he can come off isolation. 2. R2's Face Sheet printed on 2/11/25 showed R2 was diagnosed with influenza on 2/8/25. R2's Order Summary Report printed on 2/11/25 showed R2 was on droplet isolation because of influenza the order had a start date of 2/8/25 and a stop date of 2/16/25. On 2/11/25 at 9:32 AM, on the door of R2's room was a droplet/contact isolation sign. V4 (CNA) was in R2's room. V4 had on a surgical mask and no other PPE. V4 was within 6 feet of R2. On 2/11/25 at 9:36 AM, V4 said the isolation signs on the resident's door indicate what PPE staff (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: 146114 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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)