PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 000 INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 000 A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on March 26-27, 2020. This resulted in an Immediate Jeopardy at F880 that began on March 13, 2020. The Administrator was informed of the Immediate Jeopardy on March 26, 2020 at 3:30pm. The surveyors confirmed by observation, interview and record review that the Immediacy was removed on March 27, 2020. The noncompliance remained at no actual harm with the potential for more than minimal harm that is not an immediate jeopardy until continued compliance could be verified. F 880 Infection Prevention & Control SS=L CFR(s): 483.80(a)(1)(2)(4)(e)(f) F 880 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE TITLE Electronically Signed 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 1 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 2 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 2 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 3/13/20, the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH revised on 3/13/20, Nursing Home guidance from the Centers for Disease Control (CDC), and observation, interview and record review, the facility failed to ensure that: residents' movements were limited in the facility; group activities and communal dining had been canceled; social distancing for residents was monitored and maintained; residents performed hand hygiene appropriately; and, dining tables were disinfected between uses by different residents. This had the potential to affect all 195 residents in the facility and resulted in an Immediate Jeopardy (IJ) to their health and safety. The IJ began on 3/13/20, at the time of release of the revised QSO-20-14 by CMS which directed all Nursing Homes nationwide to cancel communal dining and all group activities and directed all facilities to remind residents to practice social distancing and perform frequent hand hygiene to prevent direct and indirect transmission of COVID-19. The facility is located in a county with many active cases of COVID-19 and several deaths have occurred. The facility continued to provide communal dining and group Activities. The Administrator was notified of the Immediate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 3 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 3 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 Jeopardy 3/26/20 at 3:30pm. Findings Include: At the time of the entrance to the facility on 3/26/20 at approximately 9:30am, the Administrator informed the surveyors that this was a psychiatric care facility. The residents were ambulatory and independent in activities of daily living. Observations on 3/26/20 at 9:30am, revealed the following: Approximately sixty residents were ambulating aimlessly up and down the hallways and going in and out of resident rooms on the East and West Wings of the facility. Although various licensed and non-licensed staff were seated at the front entrance to the Dining Room, or were ambulating in the hallways, staff failed to stop and re-direct residents to maintain the recommended social distancing space of six feet. Observation on 3/26/20 at 10:25am, in the Main Dining Room, revealed two residents were seated directly across from one another at a two foot wide table playing cards. These residents were R10 and an unknown female resident. Observation on 3/26/20 at 10:30am, revealed five residents congregating in the hallway outside of the Activity Room door. The Activity Director then unlocked the door and seven residents entered the Activity Room in a line without social distancing being maintained. No staff directed residents to space themselves following social distancing rules. In addition, observation revealed that residents failed to perform hand hygiene prior to entering the room from the hallways and went directly to their activities of interest. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 4 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 4 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 The size of the Activity Room was approximately 40 by 30 feet. During this observation, two residents (R2 and R7) began playing pool and two additional residents (R10 and an unidentified female resident) were seated at a table sitting directly across from each other approximately two feet apart, playing cards. Additional residents entered the small room and at one point 15 residents were in the room and were not practicing the recommended six feet of social distancing. At 10:36 am, the Activity Director opened a door from the Activity Room to an outside basketball court. Five residents (R1, R3, R5, R6 and R9) exited onto the basketball court and were observed playing basketball, which included physical contact and residents to be in close proximity to one another, while four additional residents (R4, R8 and two unidentified residents) were observed congregating on the sides of the basketball court. Observation revealed that at approximately 10:45am, the Activity Director went outdoors onto the basketball court and while outdoors, lowered his facial mask below his chin while being with the residents. During this same observation, the Activity Director rubbed his face and failed to perform hand hygiene. Following this observation, the Activity Director was questioned about the observations and verified that he forgot to wash his hands and stated, "Safety always, we are to keep our nose covered at all times, while inside and outside, I shouldn't have removed the mask." When questioned about the basketball game and maintaining social distancing, the Activity Director stated, "The basketball was a communal game and social distancing not less than six feet had not been maintained." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 5 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 5 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 When asked if residents were to perform hand hygiene prior to entering the Activity Room, the Activity Director stated "Yes, before they come into the room and when they leave the room." When asked who monitored hand hygiene, the Activity Director stated E1 (employee's name) who was seated at a table at the front of the Activity Room, who watched as residents came in and out of the Activity Room, was to monitor tht the residents had cleaned their hands. Observation on 3/26/20 at 11:52am, revealed 24 residents were lined up in the hallway outside of the Main Dining Room. All residents in the line were observed to be standing one to one-and-a-half feet from one another and some residents were positioned touching back to front of another resident. At 11:57am, when the residents entered the Main Dining Room, observation revealed that residents were not being stopped by staff and reminded to perform hand hygiene nor did staff cue any residents to maintain social distancing. Although E2 was stationed at the outer entrance to the Dining Room, to ensure that residents' maintained social distancing and performed hand hygiene, observation revealed that hand hygiene was not performed appropriately and/or not performed at all. Observation at the time, revealed that approximately twenty residents just swiped their hands at the wall hand sanitizer unit and other residents just walked by the hand sanitizer without using the hand sanitizer. During an interview with E2 on 3/26/20 at approximately 12:15pm, E2 was asked about his responsibilities. E2 stated "to make sure the residents in line for dining were standing apart FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 6 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 6 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 from each other and that residents sanitized their hands going into the Dining Room and coming out." During this same observation, R11 who was standing to the side of E2 was observed to sneeze directly into his hand, wipe his face with his hand and then entered a multi resident room without being instructed to perform hand hygiene. Review of the facility's Infection Control policy dated 3/5/20 related to the "Interim policy addressing healthcare crisis related to Human Corona Virus" related to "Hand Hygiene" indicated "HCP (Health Care Professionals) should perform hand hygiene before and after all patient contact, contact with potentially infectious material ... perform hand hygiene by using an Alcohol Based Hand Rub (ABHR) with 60-95% alcohol or washing hands with soap and water for at least 20 seconds." Continued review of the section related to "Hand Hygiene" revealed the policy did not address resident hand hygiene despite the fact that the facility had indicated that the residents were all independent with personal hygiene. Observation on 3/26/20 at 12:10pm, revealed that 43 residents were seated at the dining tables eating lunch. Forty-one of the forty-three residents were not practicing the recommended six feet of social distancing. Continued observations at this time, during the delivery of the luncheon meals to residents seated in the Dining Room, revealed that staff were not appropriately wearing face masks. Observation revealed that E3 (a dietary staff member) who was dishing out the meal onto the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 7 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 7 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 plates wore a face mask that was positioned below her nostrils and above her chin. Following the observation, E3 was asked about the position of the face mask, E3 stated "I know, it is hot." E3 then pulled the face mask up to cover her nose, but did not perform hand hygiene following the repositioning of the face mask. Continued observation during this time of the pouring and distribution of drinks to residents during the luncheon meal, revealed that E4 was wearing a face mask below her nostrils and above her chin. When E4 was asked the how the face mask should be worn, E4 stated "I know it should be over my nose." Review of the facility's "Infection Control" policy dated 3/5/20, titled "Interim policy addressing healthcare crisis related to Human Corona Virus" indicated under section "Identification and Prevention Steps" number 3 "All HCP (health care personnel) that provide direct care such as licensed nurses Certified Nurse Assistants (CNA), Qualified Medication Assistants (QMA) will be required to wear a surgical mask during their shift ...HCP must take care not to touch their facemask. If they touch or adjust their facemask they must immediately perform hand hygiene." Review of the policy revealed it failed to include instructions for dietary staff and failed to address the use of masks by these staff members. Following the completion of the luncheon meal, residents carried their dining trays and dishes to a soiled cart where the residents either scraped their uneaten items into a garbage can and/or gave their soiled dishes to a Dietary Aide. Following completion of this task, the residents exited the dining area without performing hand FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 8 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 8 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 hygiene and ambulated back into the populated hallways and/or multi resident rooms. Although E2 was still positioned at the outer entrance of the Dining Room, observation revealed that resident hand hygiene was not encouraged or enforced. During an interview on 3/26/20 at approximately 12:20pm, with the Assistant Director of Nursing (ADON) who was monitoring the dining activities at the time of luncheon meal, revealed that residents were expected to perform hand hygiene prior to entering the Dining Room and again when leaving the Dining Room. When asked how this was monitored, the ADON stated that E2 would observe hand hygiene when residents entered the Dining Room and again when residents left the Dining Room. When asked about maintaining social distancing, the ADON stated "This is a challenging population and can't always get them to do what is needed." Observation following the completion of the dining for group one on 3/26/20 at approximately 12:30pm, revealed that E5 (an environmental aide) walked into the Dining Room carrying a plastic bag. Observation revealed E5 removed a wet cloth from the bag and dropped a cloth on each of six tables. Following the placement of the individual cloths on the tables, E5 returned to table one and used the cloth to partially wiped the center surface of the table. Observation revealed that the entire surface and sides of the table had not been wiped clean with the cloth. E5 then proceeded to clean the additional tables in the same manner. Following the completion of this task, E5 was asked about the cleaning product that was being used on the tables. E5 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 9 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 9 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 "Just water, I just wet the cloths and wipe the tables down." During an interview with the Environmental Supervisor on 3/26/20 at approximately 1pm, revealed that water should not have been used to clean the tables. She stated that "Fuzion" (a select Environmental Protection Agency (EPA) product identified as a "Cleaner Disinfectant") should have been used to clean the tables. Review of the "Technical Information Clorox Healthcare Fuzion" product safety form indicated that Fuzion was identified as a registered disinfectant that had micro bacterial activity against pathogens most likely to contaminate the resident care environment. Review of the label on the Fuzion bottle revealed it was effective against the "human coronavirus." Review of the undated policy and procedure titled "Environmental Services A Key Role in Infection Prevention" revealed that "Clorox Fuzion are {sic] approved disinfecting products that are approved for COVID. The spray and wipe technique does not adequately kill ...and viruses contact time for Clorox Fuzion is 3 minutes ...Correct use of disinfectants are a priority." Observation on 3/26/20 at 2pm, at the Central Nurses Station in the presence of the Director of Nursing (DON) revealed that E6 was observed in the hallway without a face mask. When questioned about wearing a face mask, E6 stated that she was outdoors and had just returned to work. E6 stated "I forgot about the mask." Observation and validation from the DON revealed that E6 was required to wear a face mask and had walked pass the Screener at the front door and E2 (the desingated Screener) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 10 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 10 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 should have informed E6 of the requirements to wear a face mask when going onto the resident care unit. During an interview with the Administrator on 3/27/20 at 1:20pm, when asked to describe the facility's process for dining and activities, the Administrator stated, "We thought we put together an appropriate COVID-19 dining program by placing the residents 6 feet apart and minimizing the individuals in the dining room. It was once they got into the dining room, but the concern was while the residents were waiting to get in the Dining Room. They were used to lining up so it was difficult for staff to redirect." During the same interview, when asked if the dining process followed the 3/13/20 CMS recommendations for prevention of COVID-19 in long term care, the Administrator stated, "We thought it was." During the same interview, when asked if the facility's activity program followed the 3/13/20 CMS Recommendations for prevention of COVID-19 in long term care, the Administrator stated "All group activities were supposed to be canceled." Review of CDC's undated guidance titled, "Interim Additional Guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-10 in Nursing Homes," revealed the following directive for implementation by nursing homes for prevention and containment of the corona virus: "Cancel communal dining and all group activities, such as internal and external activities. Remind residents to practice social distancing and perform frequent hand hygiene." The above document further directed the following in the section titled "Resident Monitoring and Restrictions: Encourage FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 11 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 residents to remain in their room. If there are cases in the facility, restrict residents (to the extent possible) to their rooms except for medically necessary purposes. If they leave their room, residents should wear a facemask, perform hand hygiene, limit their movement in the facility and practice social distancing (stay at least 6 feet apart from others,) implement protocols for cohorting ill residents with dedicated HCP." Review of the memo QSO-20-14-NH with a revised date of 3/13/20 revealed the following under the section headed Guidance for Limiting the Transmission of COVID-19 for Nursing Homes: "Additional Guidance: 1. Cancel communcal dining and all group activities, such as internal and external group activities...3. Remind residents to practice social distancing and perform frequent hand hygiene." The Administrator was notified that the Immediacy was removed on 3/27/20 at 2:20pm, after the surveyors' verified implementation of an acceptable removal plan that included: 1. Observations and interview with the Administrator on 3/27/20 at 10am, revealed that all residents had been assessed for supervision during dining. A list of residents had been developed and residents were assigned to eat in designated areas due to medical and/or behavioral concerns. Other residents would receive meals in their rooms. Observation during the luncheon meal on 3/26/20 at 12pm, revealed that dining furniture was rearranged and one resident was assigned per table in the Dining Room and in the Activity Room in order to ensure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 12 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 490 WEST 16TH PLACE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 12 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 proper social distancing. This dining plan was monitored by the Administrator who begun auditing meals, social distancing and hand hygiene. 2. All other residents assessed as for not requiring supervision in dining ate in their rooms. 3. Observation on 3/27/20 11am, and interview with the Activity Director revealed that all group activities had been canceled. Bingo and word games were being called over the intercom while residents participated in their individual rooms. 4. During the same observations, staff and residents performed hand hygiene prior to and following dining. 5. Review of "In-Service/Ongoing Education" records dated 3/26/20 provided to all staff related to: hand hygiene, social distancing, including during smoking, and monitoring for compliance had been initiated. 6. Interviews were conducted to assess staff's knowledge related to hand hygiene, wearing of facilal mask, social distancing and new dining requirements. 7. The "Abatement Plan" was reviewed for monitoring and to ensure accountability of all corrective actions that included oversight by Administrative staff. After removal of the Immediacy, the noncompliance remained at the level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy until sustained compliance is verified. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3OJJ11 Facility ID: IL6008064 If continuation sheet Page 13 of 14 PRINTED: 04/15/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 145180 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 490 WEST 16TH PLACE CHICAGO HEIGHTS, IL 60411 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete 03/27/2020 STREET ADDRESS, CITY, STATE, ZIP CODE APERION CARE CHICAGO HEIGHTS (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED Event ID: 3OJJ11 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: IL6008064 (X5) COMPLETION DATE If continuation sheet Page 14 of 14