Health inspection·December 1, 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 interview and record review, the facility failed to identify a vascular diabetic wound until it was necrotic for one of three residents (R2) reviewed for wounds in the sample of 12. Residents Affected - Few Findings include: R2's electronic medical record show R2 was admitted to the facility on [DATE] with diagnoses that include dementia, diabetes and chronic kidney disease. On 12/1/23 at 10:22 AM, V20 (R2's son) said when R2 was still at the facility, he noted a large wound on R2's left foot by his heels that was black. V20 also said the time he was visiting R2, no staff was turning and repositioning R2. V20 said he had reported his concerns to the staff. R2's Wound Assessment detail report dated 9/27/23 show R2's Braden scale was high risk. Wound Information: -Facility Acquired, Vascular diabetic ulcer left heel. Purple ecchymosis (dark purple) 75% and necrotic 25% with bloody drainage. Wound measurement- 3.70 centimeters (cm) x 2.8 cm x 0.10 cm. R2's electronic treatment sheet dated 9/28/23 show left heel cleanse with normal saline (NSS) paint with betadine cover with ABD pad and kerlix. On 12/1/23 at 12:10PM, V8 (Wound Nurse) said R2 was admitted to the facility with no wounds. V8 said on 9/27/23, R2 was found to have an open area to his left heel. V8 said by the time the wound was found it was necrotic (with dead cells) and dark purple measuring 3.70 centimeters (cm) x 2.8 cm x 0.10 cm. V8 said staff has been told to check residents skin and report to her any abnormality. This surveyor requested R2's skin assessments prior to 9/27/23. There were no skin assessments provided except R2's shower sheet dated 9/26/23 with notes: indicate location of breakdown, heels-dark. V8 said she was not made aware of this. V8 said skin assessments should be done to check any resident skin abnormalities/open areas. On 12/1/23 at 1:45 PM, V2 (Director of Nursing-DON) said after R2's wound to the left heel was found, the care plan was updated with interventions put into place of monitoring residents skin, offloading heels and monitoring staff to turn and reposition residents in bed. V2 also said staff had to be reeducated to notify her and the wound nurse of any skin abnormality so interventions will be put into place sooner. R2's careplan shows: R2 has actual skin impairment to skin integrity and remains at risk for further skin breakdown . intervention dated 10/2/23 includes, monitor skin during AM. HS care, monitor document location size and treatment of skin injury .off load heels when in bed. Page 1 of 4 145208 145208 12/01/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place for a resident who is at high risk for falls. This failure applied to one of three residents (R1) reviewed for safety in the sample of 12. Findings include: R1's face sheet shows she is [AGE] year-old female with diagnoses including metabolic encephalopathy, dementia, unspecified severity with agitation, major depressive disorder, scoliosis, unsteadiness on feet, repeated falls, muscle weakness and difficulty walking. R1's Final Incident Report dated 11/10/23 documents on 11/8/23 at 9:00 AM, (R1) sustained a fall from her bed resulting in a laceration over her right eye requiring skin glue. R1's CNA (Certified Nursing Assistant) was completing her morning activities of daily living and when she turned to get the wheelchair, (R1) fell out of her bed. (R1) was sent out to the local hospital and returned the same day, she sustained a laceration above the right eye with skin glue applied. R1's Minimum Data Set assessment shows she's severely cognitively impaired, requires extensive two person assist with dressing and extensive assist with transfers and toileting. On 12/1/23 at 9:53 AM, R1 was observed in the dining room with a healed laceration above her right eye. R1 said she had a fall but could not recall the details. A sign was posted above R1's bed in her room showing she is extensive assist with two staff. On 12/1/23 at 9:45 AM, V11 (RN) said R1 has dementia, and her behaviors are progressing. She was R1's nurse when she fell on [DATE]. She was in another resident's room and heard crying from R1's room. When she entered R1's room, R1 was on the floor. She had a three-to-four-inch laceration above her right eye and was bleeding. V11 said V21 (Former CNA) said she rolled out of bed. V11 said she called out for help and R1 was transferred to the local hospital. She is not sure how R1 was transfered, but each resident has a sign above their bed that indicates how they transfer. On 12/1/23 at 9:57 AM, V12 (Restorative Aide) said R1 is an extensive two person assist with transfers and bed mobility. She has a history of falls and attempts to get out of bed. She was here when R1 had her fall on 11/8/23. When she entered the room, R1 was laying on the floor mat on the floor. Her bedside table was near her head. Her bed was not in the lowest position and her side rail was in an upright position. She was bleeding above her right eye. V21 (Former CNA) said she walked out of the room to grab something and R1 rolled out of bed. The bed should have been in the lowest position and the side rail should have been down. V12 said V21 no longer works at the facility. On 12/1/23 at 12:35 PM, V2 (DON) said V21 was terminated because of the incident related to R1. On 12/1/23 at 1:21 PM, V2 (DON) said V21 was providing care and left R1 at the bedside to grab a chair and R1 fell on the floor mat on the floor. She was not sure what R1 hit her head on. R1 had a laceration above her eye. R1 is a fall risk and requires two persons assist with cares. R1's bed should be in a low position and the side rails should be upright for safety. 145208 Page 2 of 4 145208 12/01/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V21's statement dated 11/8/23 documents she did not see R1 fall. I stepped out of the room to grab a chair after I dressed her. R1 rolled onto the floor from the bed. I heard her fall and she was on the floor mat. R1's current care plan initiated on 3/10/23 documents she is a HIGH risk for falls related to confusion, dementia, history of fall, muscle weakness, unsteadiness on feet and difficulty walking with interventions for a safe environment the bed in a low position and side rails as ordered. The care plan documents R1 has a self care deficit with interventions for half side rails up for safety during care provision, requires extensive two person assist with toileting, transferring and bed mobility. The facility's Fall Management Policy revised 2015 states, Based on previous evaluations and current data, the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . All residents shall be screened for the potential for falls, using the fall risk screening tool .staff will initiate falling prevention protocol . 145208 Page 3 of 4 145208 12/01/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that a resident was not housed in the same room as a resident that was placed on contact isolation to prevent the spread of infection for one of three residents (R5) reviewed for infection control in the sample of 12. Residents Affected - Few Findings include: R5's Face Sheet shows diagnoses of: malignant neoplasm of the rectum, urinary retention and colostomy. R5's Urine Culture Report from 8/17/23 shows that he has no current infections. R4's Nursing Notes date 9/25/23 shows, Resident transported into the unit .from oncology appt (infusion visit) .(urinary) catheter still in placed .chemo implanted port remain intact .resident return from appt (appointment) with a scheduled f/u (follow up) oncology/infusion visit . R4 and R5's Census Reports show that they resided in the same room on 9/27/23. R4's Nursing Notes dated 9/27/23 shows, Discussed with nurse on duty new order for Macrobid (antibiotic) 100 mg (milligrams) BID (twice a day) x 7 days r/t (related to) E.Coli ESBL (Extended-spectrum beta-lactamases) and contact isolation. R5's Census Report shows that R5 was moved to a different room on 10/2/23 (5 days after R4 was placed on isolation). R5's Nursing Notes do not document that R5 had a room change between 9/27/23 and 10/2/23. R4's Census Report shows that R4 was in the same room between 9/27/23 to 10/2/23. On 12/1/23 at 11:04 AM, V5 (Infection Control/Licensed Practical Nurse) said that anyone diagnosed with and who is receiving treatment for ESBL should be placed on isolation immediately. V5 said that if the resident has a roommate, either the resident or the roommate should be moved out of the room to prevent the spread of infection. V5 said that they have never had an issue with finding appropriate placement for a resident on contact isolation. V5 said that room changes should be documented in the nursing notes when they are done. At 2:19 PM, V5 said that when R4 developed ESBL, they spoke about it, and they were going to move R5 to a different room. The facility's Contact Precautions Policy revised on 5/22 shows, Contact Precautions require the use of gown and gloves on every entry into a resident's room. The resident is given dedicated equipment .and is placed into a private room . 145208 Page 4 of 4