F0880

E

Failure to Follow Masking and Enhanced Barrier Precaution Policies During COVID Outbreak

Elk Grove Village, Illinois Survey Completed on 12-19-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Acute Respiratory Illness Policy and Enhanced Barrier Precaution (EBP) Policy during a facility-wide COVID-19 outbreak. Upon entry, the survey team was informed by the front desk receptionist and the Director of Nursing that the facility was in COVID outbreak status, with masks and hand sanitizer available in the lobby and most staff and all visitors observed wearing masks and performing hand hygiene. Despite this, on 12-17-25, a registered nurse (V3) was observed passing medications to three residents (R45, R12, and R137) without wearing a mask, even though V3 acknowledged that the facility was in outbreak status and that staff were to wear masks and wash their hands to prevent the spread of infection. The facility’s Acute Respiratory Illness Policy dated 11-14-25 documented that the facility would recommend masking for all healthcare personnel and visitors during a facility-wide outbreak.

The facility also failed to follow its EBP Policy for a resident on Enhanced Barrier Precautions. On 12-17-25 at 5:27 PM, V3 was observed providing direct patient care by applying a pain patch to R44, who had physician orders for EBP due to wounds, an indwelling urinary catheter, and CRAB, without wearing a gown. V3 stated that R44 was on EBP but claimed not to have directly touched the resident, only the pain patch that touched the resident. The EBP policy, reviewed 6-25, documented that EBP is an approach of targeted gown and glove use during high-contact resident care activities for residents with wounds or indwelling medical devices, or with infection or colonization with MDROs. These failures had the capacity to affect four residents in a total sample of 31.