PRINTED: 09/08/2020 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: 145696 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/22/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 9777 GREENWOOD NILES NSG & REHAB CTR (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NILES, IL 60714 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) E 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 E 000 A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare * Medicaid SErvices (CMS) on 4/23/20. The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6). Total Residents 247 F 000 INITIAL COMMENTS F 000 A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on April 22, 2020 and April 23, 2020. This resulted in an Immediate Jeopardy at F880 that began on March 13, 2020. The Administrator was informed of the Immediate Jeopardy on April 22, 2020 at 4:30pm. The surveyor confirmed by observation and interview that the Immediacy was removed on April 23, 2020 at 11:45 am. 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. Total Residents: 247 F 880 Infection Prevention & Control SS=L CFR(s): 483.80(a)(1)(2)(4)(e)(f) F 880 5/12/20 §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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE TITLE Electronically Signed 05/14/2020 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: KZ7Y11 Facility ID: IL6003644 If continuation sheet Page 1 of 11 PRINTED: 09/08/2020 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: 145696 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/22/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 9777 GREENWOOD NILES NSG & REHAB CTR (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NILES, IL 60714 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 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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KZ7Y11 Facility ID: IL6003644 If continuation sheet Page 2 of 11 PRINTED: 09/08/2020 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: 145696 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/22/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 9777 GREENWOOD NILES NSG & REHAB CTR (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NILES, IL 60714 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 (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. §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: have separate areas for sorting of residents' soiled clothing and folding of residents' clean clothing and cover residents' clean clothing during transportation to prevent transmission of COVID-19. This had the potential to affect all 247 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 the Presidential declaration of a state of National Emergency for COVID-19. The facility had 31 residents and staff with confirmed COVID-19 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KZ7Y11 The following plan of correction constitutes the facility’s allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. The statements made on the plan of correction are not an admission to, and does not constitute an agreement with the alleged deficiencies herein. We respectfully submit that these deficiencies do not exist. To remain in compliance with all State and Federal regulations, the facility has taken or will take the actions set forth in the following plan of correction. F 880 483.80(a)(1)(2)(4)(e)(f) Niles Nursing and Rehabilitation Center does have an Infection Prevention and Control Program (IPCP) system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers and other individuals Facility ID: IL6003644 If continuation sheet Page 3 of 11 PRINTED: 09/08/2020 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: 145696 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 9777 GREENWOOD NILES, IL 60714 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 65 residents and staff that were persons under investigation (PUI) for COVID-19. The facility failed to have separate areas for the sorting of residents' soiled clothing and the folding of residents' clean clothing. The Administrator was notified of the Immediate Jeopardy 4/22/20 at 4:30 pm. Findings Include: Review of the facilities "Outbreak Line Listing" and "Discharged to Hospital due to Suspicion of COVID-19," dated 3/30/20 to 4/21/21, revealed the facility had 22 residents with confirmed COVID-19. Review of the facility's resident roster with persons under investigation (PUI) for COVID-19, not dated, revealed the facility had 49 residents that were PUI for COVID-19. Further review of the facility's resident roster with PUI for COVID-19, not dated, revealed the facility had residents that were PUI for COVID-19 on all four floors of the facility in which the residents resided. Review of the facility's "Staff Tracking COVID-19," dated 3/13/20 to 4/22/20, revealed that the facility had nine staff with confirmed COVID-19 and 16 staff that were PUI for COVID-19. Observation on 4/22/20 at 11:05 am, revealed the fifth floor "Resident Laundry Room" had the door open to a resident room hallway. The dryer was observed to be running. No staff were present in the "Resident Laundry Room." During the same observation, clean residents' clothing was folded on top of the washing and drying machine and an uncovered rolling cart was observed to be full with unfolded residents' clothing. During an interview on 4/22/20 at 11:12 am, with FORM CMS-2567(02-99) Previous Versions Obsolete 04/22/2020 STREET ADDRESS, CITY, STATE, ZIP CODE NILES NSG & REHAB CTR (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED Event ID: KZ7Y11 providing services based upon a facility assessment and following accepted national standards. The corrective actions that were accomplished for those residents to have been affected by the practice are: All laundry rooms on the resident’s floors were locked, disabled and shut down. There is totally no laundry operation on the resident’s floors. With the aforementioned action, all concerns of the surveyor on her report were nullified and the immediacy was removed. The corrective action remains in place to date. How other residents of the facility were identified to potentially be affected by the practice are: All residents had the potential to be affected. The facility has taken the following measures to ensure that the problem has been corrected and will not recur by: All washers and dryers on 2nd, 3rd, 4th and 5th residential floors were effectively shut down and disabled. The facility housekeeping / laundry staff will cease to use laundry equipment on the floors, instead will launder linen, that is defined as resident’s personal clothing, dirty, soiled, and used linen, infected / biohazard linen that may include resident’s clothing, in the facility’s main laundry room in the basement. All linen, including but not limited to resident’s personal clothing, will be collected by the nurses and or CNA staff, who will deposit the bagged linen through a laundry chute that is accessible and located on each floor and is funneled down to the Facility ID: IL6003644 If continuation sheet Page 4 of 11 PRINTED: 09/08/2020 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: 145696 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 9777 GREENWOOD NILES, IL 60714 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 Nursing Assistant (NA1), NA1 confirmed that the facility's housekeeping staff is responsible for laundering the residents clothing. NA1 also confirmed that the facility had one "Resident Laundry Room" on each floor of the facility where resident rooms were present. When asked if the fifth floor laundry room door should be open to the hallway with resident rooms while clean linens are uncovered, NA1 stated, "I try to tell her [the housekeeper] this door needs to be closed." Observation on 4/22/20 at 11:30 am, revealed the Housekeeper in the fourth floor "Resident Laundry Room" folding residents' clean clothing on top of the washing machine. The "Resident Laundry Room" door was open to the resident room hallway at the time of the observation. During a follow-up interview, with the Housekeeper, when asked about the facility's process for laundering residents' clothing, the Housekeeper stated that she goes room to room with a rolling bin to pick up the residents' soiled clothing and then brings the soiled clothing to the "Resident Laundry Room." The Housekeeper then stated that she sorts the residents' soiled clothing on the washing and drying machines. When asked to confirm that this was the same area the Housekeeper was folding the residents' clean clothing, the Housekeeper stated, "Yes." Observation at 4/22/20 at 11:40 am, revealed the Housekeeper transporting a rolling cart with uncovered clean residents' clothing to several rooms on the facility's fourth floor. Observation on 4/23/20 at 9:47 am, revealed the third floor "Resident Laundry Room," revealed the door was open to the resident room hallway and the drying machine was running. No staff were FORM CMS-2567(02-99) Previous Versions Obsolete 04/22/2020 STREET ADDRESS, CITY, STATE, ZIP CODE NILES NSG & REHAB CTR (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED Event ID: KZ7Y11 basement which contains a distinct and separate area for soiled and clean laundry where it is sorted, washed, dried, folded and re-distributed to the resident. The Laundry Policies and Procedures were submitted by the facility as part of the removal of the immediacy, reviewed by CMS surveyor, and determined to be in compliance with Infection Prevention and Control guidelines under F880. From 4/22/20 and 4/24/20, nursing, housekeeping and laundry staff were educated in the procedure of collecting, transferring, sorting, washing, drying, folding and delivery of clean linen consistent with the Laundry Policies and Procedures. The Laundry and Housekeeping staff underwent a competency test and all passed. All other staff who were not present on the days of the inservices were re-educated on the date of their return to work. On 05/07/20, Administrator conducted another inservice on disinfection of the washer surface openings and handles before and after every load. A laundry washing machine disinfectant log was crafted and made effective 5/7/20. On 5/8/20 to 5/11/20, the ADON also the Infection Preventionist / Nursing supervisory staff conducted another inservice on donning and removing PPE and Laundry policies and procedures. The facility has reviewed the Hazard Vulnerability Analysis and Assessment Tool and upgraded the Mass Casualty under Medical / Infectious Disease threat as well as severity of an epidemic risk to our facility. Facility ID: IL6003644 If continuation sheet Page 5 of 11 PRINTED: 09/08/2020 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: 145696 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 9777 GREENWOOD NILES, IL 60714 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 present in the room. On top of one of the drying machines, folded underwear and socks were observed with a used paper towel lying on top of the folded clothing items. During the same observation, in the hallway outside of the third floor "Resident Laundry Room" door, revealed a large black garbage bag on the floor in the hallway. A tray cart, being used to collect meal trays from residents' rooms, was observed approximately four feet from the large garbage bag. During a follow-up interview on 4/23/20 at 9:50 am, with Licensed Practical Nurse (LPN1), when asked about the "Resident Laundry Room," LPN1 stated, "It's closed." When this surveyor pointed out the open door and running drying machine, LPN1 stated, "The laundry supervisor says it was closed but there must have been a load done and then they are closing it." When asked what was in the large garbage bag outside of the third floor "Resident Laundry Room," LPN1 opened the garbage bag and revealed a large amount of soiled resident clothing. LPN1 confirmed that the bag contained resident clothing. LPN1 then stated, "Some resident may just take it and drop it." When asked where the soiled resident clothing should be placed, LPN1 confirmed that the soiled clothing should be in bins in the soiled utility room. During an interview on 4/22/20 at 2:50 pm, with the Housekeeping Director and the Administrator, when asked to describe the process for laundering of residents' personal clothing items, the Housekeeping Director revealed that the NA on the floor puts the residents' clothing in bins in the soiled utility room and then the Housekeeper will pick up the soiled residents' clothing and sort FORM CMS-2567(02-99) Previous Versions Obsolete 04/22/2020 STREET ADDRESS, CITY, STATE, ZIP CODE NILES NSG & REHAB CTR (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED Event ID: KZ7Y11 The Infection Prevention and Control Program (IPCP) manual has incorporated the Laundry Policy and Procedure for Laundry Personnel. Quality Assurance plans and monitoring practices that have been implemented to make sure corrections are achieved and are permanent are: Housekeeping / Laundry Supervisor and / or Designee will monitor the laundry staff using a Quality Assurance and Compliance tool and ensure that policies and procedures are followed weekly for the next 8 weeks and bi-monthly thereafter for the next 6 months until compliance. Employees observed not following the correct procedures will be counselled and / or disciplined as appropriate. Simultaneously, Director of Nursing, Nursing Supervisors and floor nurses and / or designee will supervise nursing staff, including CNAs in ensuring that linen, including resident’s personal clothing, will be labeled, placed in plastic bags and deposited in the laundry chute. Housekeeping Supervisor, Nursing Supervisors will report to Administrator/s and will meet weekly to discuss laundry compliance and determine a course of action should there be any report of non compliance and how it was addressed at the time. Any identified concerns will be immediately addressed. The Administrator will report the results of the audits to the Quality Assurance and Performance Improvement Committee every month. The committee will discuss Facility ID: IL6003644 If continuation sheet Page 6 of 11 PRINTED: 09/08/2020 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: 145696 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 9777 GREENWOOD NILES, IL 60714 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 the soiled residents' clothing in the "Resident Laundry Room." When asked to clarify where the soiled residents' clothing is separated, the Housekeeping Director confirmed the Housekeeper sorts the residents' soiled clothing in the "Resident Laundry Room" on top of the washing and drying machine. When asked where the Housekeeper folds the residents' clean clothing, the Housekeeping Director stated, "Inside the laundry room also. They will sanitize the top of the washer and dryer." When asked when laundry staff is sanitizing the top of the washer and dryer, the Housekeeping Supervisor stated, "They sanitize it while the washer and dryer is running and prepare it for folding." When asked the process for returning clean residents' clothing to resident rooms, the Housekeeping Director revealed that the clean resident clothing is returned in a rolling laundry cart. When asked if the Housekeeper is supposed to cover the clean clothing during transportation to the resident rooms, the Housekeeping Director confirmed that the clean clothing should be covered with "a plastic or something like that." The Housekeeping Director verified that the Housekeeper was doing the laundry on floors four and five today and another housekeeper was assigned to do laundry on floors two and three. When asked if the facility's process for sorting of dirty resident clothing and the folding of clean resident clothing was the same process on all four of the facility's the floors with resident rooms, the Housekeeping Director, confirmed it was the same process on all of the facility's floors. During the same interview, the Housekeeping Director also confirmed that the door to the "Resident Laundry Room" is to be closed anytime the staff is doing laundry. FORM CMS-2567(02-99) Previous Versions Obsolete 04/22/2020 STREET ADDRESS, CITY, STATE, ZIP CODE NILES NSG & REHAB CTR (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED Event ID: KZ7Y11 the need for additional re-education and monitoring should non-compliance be identified. Ongoing monitoring or determination of compliance will be decided by the committee if the need for further compliance need to be extended. All identified patterns and trends will be addressed and a plan implemented until resolution. Administrator and/or designee will ensure overall compliance. Completion Date: May 12, 2020 Facility ID: IL6003644 If continuation sheet Page 7 of 11 PRINTED: 09/08/2020 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: 145696 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/22/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 9777 GREENWOOD NILES NSG & REHAB CTR (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NILES, IL 60714 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 During an interview on 4/22/20 at 4:44 pm, with the Administrator and Director of Nursing (DON), when asked the reason the Housekeeper would be sorting the residents' soiled clothing, the Administrator and the DON reveal the purpose of sorting the residents' soiled linen "may be to check for linens so they don't get washed there [in the Resident Laundry Room]" and to check the residents' pockets for items. During an interview on 4/23/20 at 12:19 pm, with the Administrator, the DON, and the Assistant Director of Nursing (ADON), when asked if there is a risk for contamination of clean residents' clothing when it is folded in the same spot that soiled resident clothing is sorted, the Administrator stated, "Minimally with sanitation." When asked, what is the risk to the residents if clean clothing becomes contaminated, the Administrator stated, "Illness. Hopefully not COVID." When asked, can the virus that causes COVID-19 be transmitted on soiled clothing before a resident shows symptoms of COVID-19, the DON stated, "Yes." Review of the facility's "Laundry Policy and Procedure," not dated, revealed: "Collection of Soiled Linens: All dirty linen must be handled with care to minimize transmission of microorganisms via dust and skin scales... Soiled linen should not be placed on the floor, chair or any piece of furniture in the room... Sorting All linen can be categorized into 4 groups: Personal Clothing Dirty Linen, Used Linen Soiled Linen Infected/Bio-Hazardous Linen FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KZ7Y11 Facility ID: IL6003644 If continuation sheet Page 8 of 11 PRINTED: 09/08/2020 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: 145696 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/22/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 9777 GREENWOOD NILES NSG & REHAB CTR (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NILES, IL 60714 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 Personal Clothing: Personal clothing to be laundered by the facility is to be sorted into its own container... Folding As soon as linens are removed from the dryer, they should be sorted, folded, hung up, and readied for delivery ...There should never be a back-up of clean linens waiting to be folded... Clean linen should be transported and stored by methods that minimize microbial contamination from surface contact and airborne deposit. Clean linen should be transported in containers used exclusively for this purpose. The clean linen cart/container should be kept completely covered during transport. Laundry Room Environment... The design of the laundry should accommodate clean and dirty linen areas, .e.g. dirty linen should be brought into the laundry, processed, and come out as clean linen, without becoming re-contaminated... Laundry personnel shall be present any time the laundry equipment is operating..." According to the Centers for Disease Control, "How COVID-19 Spreads," last reviewed 4/13/2020, "...The virus is thought to spread mainly from person-to-person...Some recent studies have suggested that COVID-19 may be spread by people who are not showing symptoms...It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes...The virus that causes COVID-19 is spreading very easily and sustainably between people..." retrieved from https://www.cdc.gov/coronavirus/2019-ncov/preve nt-getting-sick/how-covid-spreads.html on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KZ7Y11 Facility ID: IL6003644 If continuation sheet Page 9 of 11 PRINTED: 09/08/2020 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: 145696 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/22/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 9777 GREENWOOD NILES NSG & REHAB CTR (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NILES, IL 60714 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 4/28/20 at 3:37 pm. According to the "Healthcare Laundry Accreditation Council Checklist Accreditation Standards, 2016 Edition:" "...Part I - 2.1.1. Based on the workflow pattern principle where processing of soiled textiles flows to clean textiles, the laundry facility's physical layout and maintenance procedures must ensure efficiency, minimize environmental contamination, and protect the material and hygienic integrity of the processed textiles. Part I - 2.1.2.1. The essential laundry facility design must have a functional separation of areas that receive, store, or process soiled textiles from areas that process, handle, or store clean textiles..." The Administrator was notified that the Immediacy was removed on 4/23/20 at 11:45 am, after the surveyor verified implementation of an acceptable removal plan that included: 1. Observations on 4/23/20 at 10:45 am to 11:45 am, of the second, third, fourth, and fifth floor "Resident Laundry Rooms" revealed the doors had been locked and the washing and drying machines had been disabled. Interview during the same observations with the Maintenance Director revealed that the facility had determined that the residents' clothing would be laundered in the facility's main laundry room which contained distinct, separate areas for clean laundry and soiled laundry. 2. Review of In-Service Education records dated 4/22/20 and 4/23/20 provided to nursing, housekeeping, and laundry staff related to the procedure of collection of soiled laundry, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KZ7Y11 Facility ID: IL6003644 If continuation sheet Page 10 of 11 PRINTED: 09/08/2020 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: 145696 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/22/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 9777 GREENWOOD NILES NSG & REHAB CTR (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NILES, IL 60714 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 transferring soiled linen, sorting folding, and delivery of clean linen. 3. Interviews were conducted to assess staff's knowledge related the process for laundering residents' personal clothing. 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: KZ7Y11 Facility ID: IL6003644 If continuation sheet Page 11 of 11