Inspection·March 31, 2023

F 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to operationalize its Covid-19 Policy and to follow CDC (Centers for Disease Control) guidelines by testing and immediately isolating two residents (R9, R11) with respiratory symptoms consistent with infection by the Covid-19 virus. This failure has the potential to affect all 25 residents living at the facility. Residents Affected - Many Findings include: 1. R9's Nursing Progress Notes dated 3/17/23, all authored by V3 (Registered Nurse/RN) documented the following: 1:00pm: o2 sat (Oxygen Saturation) (dropped to) 87% (percent), o2 at 2 liters via NC (Nasal Cannula) applied. 3:00pm: o2 sat at 96%, will continue to monitor. 5:45pm: (V11/Physician) (was) called with condition report regarding o2 (sat) dropping. Applied 2 liters o2 via NC. With the o2 her sat came up to 96%. We will continue to monitor . There was no documentation in these notes to indicate R9 was rapid tested for Covid, nor that R9 was isolated upon displaying symptoms suggestive of infection with Covid. According to https://www.medicinenet.com/what_are_blood_oxygen_levels/article.htm, normal range for oxygen saturation is 95-100%. A Nursing Progress Note dated 3/18/23 at 11:40am authored by V5 (RN/Infection Control Preventionist) documented: Upon obtaining vital signs, CNA (Certified Nursing Assistant) notified (this) nurse of (R9's) pulse (being) 125 (beats per minute). o2 (sat) 90 (percent) on 3 liters (o2). (V11) (was) notified of condition and gave orders to send (R9) to emergency room for evaluation and treatment. A 3/18/23 Hospital admission History and Physical documented, W/U (Work up) in ED (Emergency Department). CXR (chest x-ray) remarkable for bilateral patchy infiltrates, small pleural effusion. Covid lab test-negative. February and March 2023 Covid Testing Logs document that the facility had not done Covid testing on any residents or staff members since 02/03/23. On 3/31/23 at 8:39am, V3 stated that when R9's o2 sats decreased on 3/17/23 as outlined in the above referenced nurses notes, R9 began complaining of shortness of breath. V3 acknowledged shortness of (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: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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)