F0880

D

Failure to Post Isolation Signage for Residents on Enhanced Barrier Precautions

South Beloit, Illinois Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program when two residents on isolation-level precautions did not have isolation signage posted on their room doors. One resident was admitted with diagnoses including Parkinson’s disease, surgical site aftercare, and a urinary tract infection, was cognitively intact, and required moderate assistance with ADLs. A physician order dated 12/12/2025 directed the use of Enhanced Barrier Precautions (EBP) for this resident. Another resident was admitted with diagnoses including surgical aftercare, pressure ulcers, type 2 diabetes, and wound infections, was cognitively intact, and required partial assistance with ADLs. This second resident had a physician order dated 11/4/2025 for contact isolation, and a care plan dated 11/6/2025 with a revision on 12/19/2025 indicating a need for strict isolation precautions.

On 3/3/2026 at 1:00 PM, surveyors observed that there were no isolation signs on the doors of either resident’s room, despite the existing orders and care plan for EBP and isolation. At 1:30 PM the same day, the Director of Nursing confirmed that both residents had orders for EBP and acknowledged that signs should have been on their doors to alert staff to use appropriate PPE to prevent the spread of infections. The Director of Nursing further explained that one resident’s contact isolation had been changed to EBP after diarrhea resolved, and stated that the signs should have been moved when the residents changed rooms. The facility’s undated infection prevention and control manual for EBP states that EBP is intended to reduce transmission of multi-drug-resistant organisms and involves the use of gown and gloves during high-contact resident care, underscoring that signage was an expected component of implementing these precautions.