DECATUR, Ill. (WCIA) — If you saw a food service worker return to work without washing their hands after using the bathroom, you would probably think twice about returning to that restaurant.
At a nursing home, you might feel the same way if you noticed healthcare workers not washing their hands or using proper protective equipment before providing care.
According to state inspection reports submitted in 2019 to the U.S. Centers for Medicare & Medicaid Services (CMS), maintaining proper hand hygiene practices and use of protective personnel equipment (PPE) was reported as an issue for multiple nursing homes in Central Illinois.
Karen Liu reported Thursday for CU-Citizen Access that over half of the nursing homes in the State of Illinois that are Medicare or Medicaid certified were cited in 2019 for deficiencies in their infection prevention and control programs. Her investigation found 396 of 720 active nursing homes had been cited for such deficiencies.
In an inspection report dated Jan. 9 of this year, Prairie Creek Village in Decatur was cited for failing to follow ‘contact precautions.’ The report stated two certified nurse assistants (CNA) failed to wear gowns while caring for a resident who was experiencing urine incontinence. They also did not wash their hands after removing their gloves when they finished providing incontinence care.
The CNA told inspectors that “we don’t wear gowns when we do incontinence care, that’s only when the nurses do wound care.” The report added two CNAs at Prarie Creek Village were unable to “verbalize the reason for not utilizing barrier precautions.”
In another case, PPE simply wasn’t accessible to healthcare workers. An inspection report dated May 17, 2019 cited Gardenview Manor in Danville for failure to follow “Transmission Based Protocols” for two of their residents. One of those residents was on contact isolation due to wound infection, and a CNA reportedly failed to wear a gown when caring for them.
The report stated two of their CNAs “acknowledged they were suppose to have gowns on, but the rack on the door for PPE was empty of gowns.”
As for the other protocol violation, a registered nurse (RN) admitted they were supposed to have worn a mask before entering the room of a resident on ‘Airborne Precaution.’
WCIA examined these inspection reports, which are available for public access on the Medicare.gov webpage for comparing nursing homes, and reached out to many of the violating facilities for comment on how they responded to their citations.
In an August 5, 2019 inspection report, Lewis Memorial Christian Village in Springfield was cited after one of their CNAs failed to wash their hands in between changing gloves during wound and incontinence care.
Ray Dickison, Chief Operating Officer for Christian Horizons, which manages that facility, provided the following statement Wednesday.
On August 5, 2019, our community received a minor deficiency related to infection control involving a sample of 5 residents that resulted in no harm to any of the residents. In response to the citation, our community developed and implemented a plan of correction which was submitted, reviewed and approved by the Illinois Department of Public Health (IDPH). IDPH subsequently confirmed correction and our compliance on September 24, 2019. Our community remains in compliance to infection control regulations and also implemented an infection preventionist role on the clinical team.
Ray Dickison, Chief Operating Officer for Christian Horizons.
He added their organization took the following steps in preparation for the COVID-19 pandemic.
- Conducted additional staff training on COVID-19, hand hygiene, isolation precautions, and infection control policy and procedures.
- Implemented measures from the Centers for Disease Control (CDC), CMS and state guidance for enhanced infection prevention. These measures included training, revised cleaning guidelines, daily screenings of associates and residents and visitation restrictions.
- Purchased additional PPE and implemented optimization measures for supply and equipment management.
- Completed an enhanced infection control assessment and follow-up action plan that continues to be monitored.
Champaign Urbana Nursing and Rehab Center was cited in a report dated Oct. 18, 2019, for failure to utilize proper handwashing practices or PPE in two separate instances.
Kansas Swain, Director of Publications for Premier Healthcare Management, said in an emailed statement Wednesday Champaign Urbana Nursing and Rehab was in compliance with all regulatory requirements, “including infection control requirements.”
“Resident safety is our top priority,” Swain added. “We are doing everything we can to ensure we prevent any cases of COVID-19 within our facility, including following all local, state, and federal health department guidelines to ensure we are taking all appropriate actions.”
Springfield’s Aperion Care Capitol was cited Aug. 30, 2019 after state inspectors found their facility was not following proper isolation precautions, and a CNA failed to wash their hands after providing incontinence care.
Heather Levine provided the following statement on behalf of Aperion Care, Inc.
Aperion Care is taking a proactive approach in protecting our residents by following the recommendations of the CDC & CMS on prevention methods, including following strict handwashing procedures, and in many circumstances, wearing gowns and gloves when interacting with residents who are sick. We also are staying up to date with the CDC recommendations as they are revised. In addition, our facilities are in close contact with the local and state health departments and are following their guidance. We have a certified infection preventionist through the Association for Professionals in Infection Control to assist with implementing the CDC recommendations. We are also a Joint Commission accredited facility that completes monthly handwashing competencies with our staff. We use these competencies as an opportunity for improvement and education while reviewing trends. We have eliminated all visitors coming into our nursing facilities until further notice. We are also screening each staff member as they report to work each shift.
HEATHER LEVINE
“Nursing home facility staff should always follow the infection control guidance from the CDC, IDPH, and their local health department, especially during the ongoing COVID-19 pandemic,” said Kelly D. Richards, Illinois State Long-Term Care Ombudsman. “If individuals are aware of facilities not following infection control guidance, they can file a complaint with the Illinois Department of Public Health at dph.ccr@illinois.gov or by calling 1-800-252-4343.”
WCIA reported Wednesday that two additional residents died at the Fair Havens Senior Living nursing home in Decatur. A total of five of their residents have passed after contracting COVID-19.
Fair Havens was not cited for any infection control and prevention deficiencies in 2019, according to the most recent inspection reports hosted on Medicare.gov.
A full summary of all inspection reports completed since 2019 containing violations for infection control and prevention that were examined by WCIA for this story can be found below:
CHAMPAIGN COUNTY
- Champaign Rehab Center
- Failed to obtain orders for isolation.
- Failed to post signage to indicate isolation.
- Champaign Urbana Nursing and Rehab
- Failed to prevent cross-contamination from resident’s infection by not wearing required PPE.
- County Health Care and Rehab
- Failed to perform hand washing.
- Failed to follow contact precautions.
- Failed to decontaminate an insulin pen prior to use and storage.
- Illini Heritage and Rehab Center
- Failed to implement contact isolation precautions due to improper use of PPE.
- University Rehab Center of CU
- Failed to ensure staff use PPE when delivering direct care to a resident on Contact Isolation Precautions and preventing cross-contamination.
COLES COUNTY
- Charleston Rehab and Healthcare
- Failed to thoroughly wash hands during wound treatment for a resident needings dressing changes
- Mattoon Rehab and Healthcare Center
- Failed to implement and follow ‘Transmission Based Precautions’ for a resident with a known infection, resulting in cross-contamination during incontinence care.
- Odd Fellow-Rebekah Home
- Failed to ensure that staff and visitors use appropriate PPE for a resident on transmission-based precautions. In this case, a CNA told a visitor wearing PPE was ‘optional.’
- Palm Terrace of Mattoon
- Failed to use PPE while providing toileting care and a wound dressing change for a resident on contact isolation precautions
DOUGLAS COUNTY
- Arcola Healthcare Center
- Failed to perform handwashing and properly disinfect a glucometer after use for six residents.
- Failed to implement and monitor the facility’s water management program to address the potential waterborne pathogens for contamination of the facility’s residential water distribution system.
- Tuscola Healthcare Center
- Failed to develop a water management plan that included a risk assessment and testing protocols.
EDGAR COUNTY
- Paris Health Care Center
- Failed to develop a water management plan that included a risk assessment and testing protocols.
- Failed to disinfect the top of an insulin vial before drawing up the insulin.
- Pleasant Meadows Senior Living
- Failed to ensure fingernails and bed sheets were clean and failed to keep a catheter bag off of the floor to prevent cross-contamination.
- Failed to post signage to indicate isolation.
- Failed to appropriately sanitize scissors.
- Twin Lakes Rehab and Healthcare Center
- Failed to prevent cross-contamination by not performing handwashing during intramuscular (IM) medication administration.
IROQUOIS COUNTY
- Sheldon Healthcare Center
- Failed to wash hands and use PPE when caring for multiple residents. In this case, a CNA provided bathing assistance for a resident wehile wearing gloves that were contaminated from providing incontinence care. An RN also did not wash their hands before or after administrating medication.
- Failed to have completed their Water Management Plan and testing protocol.
- Watseka Rehab and Healthcare Center
- Failed to have an Infection Prevention and Control Program that tracks and analyzes resident and employee infection data to identify trends or patterns.
- Failed to disinfect a glucometer after use and prior to placing on top of a medication cart
- Failed to use PPE.
- Failed to perform handwashing during incontinence care and wound care.
MACON COUNTY
- Imboden Creek Living Center
- Failed to protect resident flooring from cross-contamination during isolation room cleaning. In this case, soiled clothes were dropped on the floor instead of being placed in a plastic bag.
- Prairie Creek Village
- Failed to review or update their infection control policy at least annually.
- Failed to address or identify infection trends.
- Failed to follow contact precautions.
- Failed to handle soiled linens in a sanitary manner and maintain laundry equipment in a sanitary condition so as to prevent the spread of pathogens.
- Villa Clara Post Acute
- Failed to change a water filter per manufacturer’s directions to prevent bacteria accumulation in an ice machine.
- Failed to follow their emergency interdisciplinary plan to monitor for signs, and symptoms of infection related to Legionella contaminated water.
PIATT COUNTY
- Bement Healthcare Center
- Failed to have an Infection Control Program that tracks and analyzes resident and staff infection data to identify trends and patterns.
- Piatt County Nursing Home
- Failed to develop and implement a water management program to address the potential for waterborne pathogens in the facility’s residential water distribution system.
SANGAMON COUNTY
- Aperion Care Capitol
- Failed to wash hands before leaving a resident’s room after performing care.
- Failed to identify a potential eye infection.
- Failed to maintain isolation precautions for residents with known infectious diseases.
- Auburn Rehan & Healthcare Center
- Failed to complete an ongoing infection control program.
- Failed to maintain infection control practices. In this case, two CNAs did not wash their hands before handling a resident’s personal items.
- Concordia Village Care Center
- Failed to properly disinfect multi-use glucose monitors to prevent the spread of infection.
- Failed to wash hands before or after caring for residents. In this case, an RN administered medications without washing their hands first. The RN previously helped a resident blow their nose.
- Heritage Health-Springfield
- Failed to wash hands and change gloves during incontinence care.
- Lewis Memorial Christian Village
- Failed to wash hands to prevent the spread of infection during incontinent care and wound care.
- Regency Care
- Failed to wash hands in between glove changes or after touching residents’ personal items.
- Villa Health Care East
- Failed to properly disinfect blood glucose meters.
- Failed to wash hands before and after resident care.
VERMILION COUNTY
- Gardenview Manor
- Failed to make PPE accessible to staff.
- Failed to develop a water management plan that included a risk assessment and testing protocols.
- Hawthorne Inn of Danville
- Failed to develop a water management plan including a risk assessment and testing protocols.
- Failed to follow infection control practices by failing to remove contaminated gloves and wash hands after caring for residents
- Failed to disinfect a blood glucose monitor after use.
- Heritage Health-Hoopeston
- Failed to wear PPE when providing direct care for residents in isolation.
- Failed to have PPE accessible to staff.
- Failed to wash hands after touching an electronic device.
- North Logan Healthcare Center
- Failed to develop and implement a water management program to address the potential for waterborne pathogens in the facility’s residential water distribution system.
- Failed to perform infection surveillance and data analysis of facility infections.
- Failed to prevent potential cross-contamination by placing soiled linens and a soiled incontinence brief on the floor.
- Failed to change gloves during incontinence care.
