Health inspection·November 3, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure ongoing assessment, identifying, and reporting of new skin impairment for a resident that is at risk. The facility also failed to follow manufacturer recommendation when using a low air loss mattress. This deficiency affects one (R12) of three residents in the sample of 20 reviewed for Wound/Skin Prevention Management. Residents Affected - Few Findings include: On 10/31/23 at 11:50AM, observed R12 lying in low air loss (LAL) mattress bed. R12 said that his buttocks hurt. Called V9 (Registered Nurse/RN) to check and assess resident's back. Observed multi-layer linen over the LAL mattress. There was a flat sheet, folded linen in quarter, 2 cloth pads and disposable chucks over the LAL mattress. R12 is wearing disposable brief. V9 said that R12 should only be on flat sheet over the LAL mattress. There should not be multi-layers of linen because it depletes the purpose of the LAL mattress. On 10/31/23 at 12:07pm, informed V2 (Director of Nursing/DON) of above observation. V2 said that R12 should only be on a flat sheet over the LAL mattress. There should not be multi layers of linen. Requested the policy on wound care prevention and LAL mattress protocol. On 11/1/23 at 10:30AM, V14 (Wound Care Nurse/WCN) said that R12 has history of MASD (Moisture Associated Skin Disorder) that was healed months ago. Observed V13 (Certified Nursing Assistant/CNA) reposition R12 so V14 could do a skin assessment on the sacral area. Observed R12 had MASD with open wounds on both the right and left buttocks with white paste medication applied. V14 cleansed the sacral area, assessed, and measured the open wounds. V14 said that R12 has MASD with open wound on left para sacral measures 6cm x 3.5cm x 0.2cm and right para sacral measures 4cm x 3.5cm x 0.2cm. V14 said that both has superficial open wound. V14 said that he was not aware that R12 had re-opened his MASD. He has not seen him since he healed the MASD months ago. V14 said that nurses and CNAs should notify him if they observed the open wound or any skin impairment. Any skin impairment should be assessed, notify the physician to obtain appropriate treatment and update family member for wound treatment and management. On 11/1/23 at 10:35AM, V13 (CNA) said that she did not report it to the nurse because she has seen R12 with the open wound on sacral area since last week. On 11/2/23 at 10:22AM V14 (WCN) said that he is responsible for skin assessment to all residents, to prevent and treat wound, and to implements wound care interventions. V14 said that R12 was initially admitted on [DATE] with admission Braden scale/skin assessment indicating at high risk for skin impairment. R12 had facility acquired MASD on 3/29/23. It was healed on 5/26/23. R12's most recent Page 1 of 5 145026 145026 11/03/2023 Westminster Place 3200 Grant Street Evanston, IL 60201

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Braden scale/skin assessment done on 10/26/23 indicating at high risk for skin impairment. V14 has not seen and assessed R12 since wound healed. He did not do weekly skin assessment for R12 because he does not have skin impairment. He only does weekly assessment if resident has active wound. Weekly skin assessment should be done be nursing and documented in progress notes. There was no skin impairment reported to him by the nurses and CNAs for R12. He only found out about R12's re-opened MASD when the surveyor asked him to do the skin assessment. V14 said that nurses and CNAs should notify him if they observed open wound or any skin impairment. Any skin impairment should be assessed, notify the physician to obtain appropriate treatment and update family member for wound treatment and management. V14 said that there should be no multilayers of linen over the LAL mattress. Only a flat sheet and 1 cloth pad. V14 is not sure if they have policy or protocol for using LAL mattress. On 11/2/23 at 10:57AM, V2 (DON) said that when CNAs observe any open wound or skin impairment, they notify the nurse. The nurse then should assess the skin impairment, call the physician or Nurse Practitioner, and update the family member. R12 is admitted on [DATE] with diagnosis listed in part but not limited to Muscle weakness, Post polio syndrome, Noncompliance with medical treatment regimen, Malignant neoplasm of prostate. Active physician order sheet indicates: Remedy Phytophex Z-Guard (Zinc Oxide)17-57% topical paste applies to sacral/buttocks/groin/perineal/scrotal areas post soap and water wash two times daily and as needed. Weekly skin assessment. Low air loss mattress by shift. Care plan indicates: R12 is at risk for pressure ulcer related to weakness, impaired mobility, incontinence, history of comminuted fracture of posterolateral aspect of humeral head and a fracture line at anatomic neck of left humerus, history of polio lifelong with left side weakness/flaccid. He prefers to stay in bed and refused to get out of bed when encouraged. R12's wound assessment completed by V14 (WCN) on 11/1/23 indicates: Left para sacral MASD measures 6cm x3.5cm x0.2cm, 75% bright red, 25% non-granulating tissues. Right para sacral MASD measures 4cmx 3.5cmx 0.2cm, 80% bright red, 20% non-granulating tissues. Facility's policy on Prevention and healing of pressure injuries and non-pressure related injuries indicates: I. Purpose: Residents at this facility will not develop clinically avoidable pressure injuries. Resident admitted with pressure injuries will receive care and services to promote healing and prevent further injuries. Residents with non-pressure related injuries will receive care and services according to current standards of practice. II. Statement of policy: Provides care and services to: *Promote the prevention of pressure injury development Procedure: c. Weekly physical assessment of skin throughout stays. C. Monitor/evaluate: 145026 Page 2 of 5 145026 11/03/2023 Westminster Place 3200 Grant Street Evanston, IL 60201

F 0684 a. Nursing assistant observes and reports alteration in skin integrity. Notify nurse of any change in skin condition. Level of Harm - Minimal harm or potential for actual harm b. Nurse evaluate skin condition weekly or more often if indicated. Residents Affected - Few Facility's policy on Use of Support Surfaces indicates: Policy explanation and compliance guidelines: 6. Support surfaces will be utilized in accordance with manufacturer recommendation. 8. Limit the amount of linen and pads placed on the bed. 145026 Page 3 of 5 145026 11/03/2023 Westminster Place 3200 Grant Street Evanston, IL 60201

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to use appropriate PPE (Personal protective equipment) for a resident on droplet and contact isolation. The facility also failed to perform hand hygiene after removing and donning gloves during incontinence care. This deficiency affects one (R42) of three residents in the sample of 20 reviewed for infection control. Residents Affected - Few Findings include: On 11/1/23 at 10:00am observed R42's door with a posting of Special Droplet/contact precautions. On 11/1/23 at 10:20AM, observed V13 (Certified Nursing Assistant/CNA) after providing incontinence care to R42. V13 rolled the soiled linen toward R42 and tucked it underneath her while V14 (Wound Care Nurse/WCN) was holding R42 in a side lying position. V13 removed her soiled gloves, took a clean flat sheet, and covered the mattress with her bare hands. V13 realized that she was not wearing gloves. She donned gloves without hand hygiene. On 11/1/23 at 10:35AM, informed V13 (CNA) and V14 (WCN) of the observation made while observing incontinence care and wound care to R42. V13 said that she should wear gloves when making the bed for a resident on isolation precaution. She should have washed her hands after removing and before wearing gloves during incontinence care. On 11/1/23 at 10:55AM conducted an interview with V3 (Infection Preventionist). Informed V3 of the observation made with V13 (CNA). V3 said that V13 should perform hand hygiene after removing gloves and donning gloves during incontinence care. Facility's policy on Isolation for Infectious Diseases 7/18/23 indicates: Purpose: To prevent transmission of infectious disease. Special Droplet/contact precaution- Residents who are suspected to be infected with microorganism transmitted by droplets (large-particle droplets) that can be generated by the resident coughing, sneezing talking or procedures such as suctioning: 11. Sets up isolation equipment as follows: c. Places bedside cabinet or isolation cart outside resident's room and ensures stock of clear garbage bags, red plastic infectious waste bags, yellow or blue plastic linen bags (depending on color used at community), gloves, gowns, eye protection, and masks and single use thermometers, stethoscope, and sphygmomanometer as appropriate. Facility's poster for Special droplet/contact precautions from CDC posted outside R12's door indicates: In addition to standard precautions. Only essential personnel should enter this room. If you have questions, ask nursing. Everyone must: including visitors, doctors, and staff. 1. Clean hands when entering and leaving the room. 145026 Page 4 of 5 145026 11/03/2023 Westminster Place 3200 Grant Street Evanston, IL 60201

F 0880 2. Wear Mask. (Fit tested N95 or higher required when performing aerosol-generating procedures) Level of Harm - Minimal harm or potential for actual harm 3. Wear eye protection. (Face shield or goggles) 4. Gown and glove at the door. Residents Affected - Few 5. Keep door closed. 6. Use patient dedicated or disposable equipment. Clean and disinfect shared equipment. Facility's policy on Hand hygiene 9/21/21 indicates: I. Purpose: To prevent the spread of infection and to maintain asepsis. II. Statement of policy: Hand hygiene is essential for preventing the spread of infectious organism in health care settings. The center for Disease Control and Prevention (CDC) and Illinois Department of Public Health (IDPH) recommend the routine use of alcohol- based hand rubs (ABHR) over soap and water due to improved adherence, effectiveness, and accessibility except in situations where soap/water handwashing is specifically recommended. This table below provided by the CDC summarizes the recommended uses of the two forms of hand hygiene. 145026 Page 5 of 5