Inspection·December 6, 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** 2. On 12/5/23 at 9:07 AM, R102 was lying in bed on her back with both heels resting directly on a pillow. R102's heels were not floated and a pair of heel protectors were on the floor in the corner of the room. Residents Affected - Few On 12/5/23 V4, Licensed Practical Nurse (LPN), removed R102's non-skid socks to visualize the dressings she had to each heel. After replacing R102's socks, V4 placed R102's heels back onto the pillow without floating/offloading her heels. On 12/5/23 at 9:51 AM, V23, Wound Care Registered Nurse (RN), said R102 needs to always wear her padded booties to both heels. V23 said R102's heels should not be resting directly on the mattress or on a pillow. R102's Order Summary Report printed 12/5/23 shows R102's heel protectors should be used to offload her heels while R102 is in bed and as needed. R102's wound care provider notes from 10/16/23 show under Preventive Measures in Place the following: General- Avoid bony prominence under direct pressure and Heels-Offload with heel protectors or pillow. R102's admission Record dated 12/5/23 shows her diagnoses include, but not limited to, diabetes, osteomyelitis of the right ankle and foot, need for assistance with personal care, end stage renal disease, and dependence on renal dialysis. R102's Minimum Data Set (MDS) dated [DATE] shows R102 requires substantial/maximal assistance with her ability to roll from lying on back to left and right side and return to lying on back. The facility's Wound Management Program Policy, not dated, shows the facility will employ pertinent aspects of wound care including management of tissue loads, prevention of wound development and support for the healing of wounds that are present. 3. On 12/4/23 at 11:51 AM, R116 said he has many appointments and the facility does not provide transportation so the appointments must be rescheduled. On 12/5/23 at 1:18 PM, V18, Transportation Coordinator, said it is the facility's responsibility to provide transportation to the resident's appointments. V18 said R116 missed his appointment last week because his transportation did not show up. The reception told R116 he did not go out to his wound care appointment but she got busy and did not reschedule it. V18 said there was no way to find transportation for R116's appointment for tomorrow (12/6/23). V18 was not informed of the appointment in time, so V18 had to reschedule it. V18 said R116 needs transportation with a lift because he has an electric wheelchair. V18 said they have a transportation van but sometimes the van lift is not working. V18 said the lift of the van has been broken for two to three weeks now. On 12/5/23 at 1:49 PM, R116 said the nurse made his appointment scheduled for tomorrow. On 12/06/23 at 08:56 AM, V14, LPN, said wound care wants to see R116 weekly in their clinic. V14 said she had scheduled R116's wound care appointment for today, but it was rescheduled because there was not enough notice to set up his transportation. R116's MDS dated [DATE] shows he is cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's Scheduling Transports Policy (undated) shows the facility is responsible to make other transport arrangements if facility transport is not available. Based on observation, interview and record review the facility failed to ensure wound treatments were completed and wound interventions were in place for residents with non-pressure wounds and failed to schedule transportation for a residents physician appointments for 3 of 35 (R24) (102) (R116) reviewed for quality of care. Findings include: 1. R24's electronic face sheet printed on 12/6/23 showed R24 was admitted to the facility on [DATE] with diagnoses to include but not limited to non-pressure chronic ulcer of skin of other sites with necrosis of muscle, unspecified open wound, left hip, infection following a procedure, other surgical site, Sequela. R24's physicians order sheet (POS) printed on 12/6/23 showed left hip lateral /distal cleanse with Hibiclens loose packing, iodoform calcium alginate foam dressing BID (twice daily) and prn (as needed) two times a day for wound care. Left hip distal cleanse with Hibiclens irrigate/ calcium alginate over wound, cover with super absorbent pad dressing daily BID and PRN as needed for wound care. R24's minimum date set (MDS) printed on 12/6/23 showed R24 to be moderately cognitively impaired. R24's care plan printed 12/6/23 showed administer wound care (Treatment) per MD orders (See POS/TAR) for current orders. R24's treatment administration record (TAR) printed on 12/6/23 showed for the month of November R24's dressings were changed for the left hip distal and left hip lateral. For the distal hip it showed dressing was changed twice a day for two days out of thirty and three days out of thirty the dressings were not changed at all. The month of December showed R24's dressings were changed twice a day for one day out of five days. On 12/05/23 at 9:58 AM, V23 (Wound Care Nurse) WCN said R24 had a post-surgical wound for a left hip implant. V25 said, the wound is surgical and it is open. We are using a super absorbent pad because it is draining. On 12/06/23 at 10:02 AM, V23 (WC) said the anterior wound is closed and the left hip proximal and distal hip has two openings. V23 said, The left proximal hip in-depth is deep, the surrounding area is ok. We are doing protective dressings anterior because it is chronic. On the lateral we have iodoform packing and calcium alginate covered with super-absorbent pad. The distal we are doing clean with Hibiclens and calcium alginate and super absorbent pad. On 12/06/23 at 12:09 PM, V24 (Certified Nursing Assistant) CNA said, I would tell the nurse if I saw a dressing coming off so they could come and put another one on to protect the wound. On 2/06/23 at 12:10 PM, V17 (License Practical Nurse) LPN said R24's left lateral and distal hip areas are to be changed twice a day. V17 said, If it is not done, R24 could get an infection. It could infect the wound even more. It could start another wound as well if it is not cleaned and it could lead to even more damage. It could cause delay in healing and cause bacteria to build up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/06/23 at 12:13 PM, V23 (Wound Care Nurse) stated R24's dressings are to be changed twice a day. R24 has two areas to be changed twice a day. The left hip lateral distal and left hip distal. V23 said there will be a lot of drainage and it will get more infected and be hard to heal if dressings not changed. It also would delay healing. The facility's guidelines, policy, procedure for non-sterile dressings dated 5/23 showed verify there is a physician's order for the procedure by reviewing the resident's treatment administration record . The facility's wound management policy 05/1917 showed a wound is a disruption in skin integrity and may include a break in the skin or damage to the underlying tissue. Wounds cause significant morbidity and mortality . It is cost effective to prevent wounds rather than heal wounds . this facility will have an ongoing organized approach to wound care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 a resident with dysphagia was supervised during meals. The facility also failed to ensure a resident's call light was placed within his reach. This applies to 2 of 35 residents (R57, R28) reviewed for safety and supervision in the sample of 35. 1. On 12/5/23 at 8:48 AM R57 was sitting up in bed in his room at the end of the hall, feeding himself breakfast. R57 had food particles all over his face, chest, and bedding. R57 stated he did not need any help and confirmed he was able to feed himself. No staff was present in R57's room or in the hallway. On 12/6/23 at 9:00 AM R57 was again seen feeding himself breakfast. R57 had scrambled eggs on his chest and chin and some on the floor next to his bed. V12 (CNA) was in another resident's room in the middle of the hall assisting that resident to eat. No other staff were present in the hallway. On 12/6/23 at 8:40 AM V12 stated, (R57) can feed himself , he needs a little set up but he feeds himself. He makes a mess too but he can feed himself. On 12/06/23 at 9:11 AM V11 (RN) stated, He is one of those persons that won't let you feed him. I have never received any reports of him coughing or choking. He was on Hospice but his family took him off. His wife comes and sits with him about every other day. He doesn't want to come out here to the dining room, we have tried. There is always a CNA in the hallway, looking out and watching him. On 12/6/23 at 9:45 AM V9 (Speech Therapist) stated, He is on a mechanical soft, thin liquids diet. He is a challenging gentleman, he refuses everything. I have not worked with him since May 2023. He is missing a lot of teeth and has a cognitive decline so that is causing some of the dysphagia. We are just trying to keep him safe. When I was seeing him, he would refuse supervision. He needed to have the tray set up and then would kick everyone out of the room. At that time, he would not need direct supervision but just someone checking in on him from the hallway. V9 was shown the order on R57's current Physician's Order Sheet that states, 1:1 Feeding Supervision every shift for monitoring reminder dated 9/12/23. V9 stated, That was a nurse who put that order in and I don't know why. I have not seen him since May. R57's Physician's Order Sheet shows he was last admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Schizophrenia, Degenerative Basal Ganglia, Parkinsonism and Dysphagia. R57's current care plan shows a Focus area dated 4/13/23 and states, I demonstrate some or high risk to potentially choke, aspire foods or liquids. This problem is related to: Diagnosis of Dysphasia. This care plan was revised on 9/16/23 with a target date of 10/3/23. One of the Interventions for this Focus area is : Observe the resident during mealtimes for any signs/symptoms of aspiration or difficulty swallowing. 2. R28's Facility assessment dated [DATE] showed R28 to be a ninety-three-year-old male with moderate cognitive impairment and needing partial to moderate assistance with toileting and transfers. On 12/4/23 at 2:00 PM, R28 was in bed resting with the television on. When R28 was asked if he used the call light to call staff, R28 responded yes. R28 then started looking for his call light and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said, I don't see it at the moment. R28's call light was on the arm rest of the recliner chair opposite to the bed approximately 3-4 feet away. R28 stated he got back into bed before lunchtime so he could eat and rest. On 12/5/23 at 10:10 AM V3 Licensed Practical Nurse stated before leaving the room call lights should be placed within reach of the residents to try and reduce possible falls. On 12/5/23 at 10:15 AM V16 CNA stated R28 will use the call light to get a hold of us when he needs anything or needs help with toileting/getting cleaned up. The call light needs to be in reach so a resident does not attempt to get up by themselves if they need assistance. R28's Fall Risk Review dated 10/30/23 showed R28 is at high risk for falls. The facility's undated Call Light Policy showed .Always place the call light in an accessible location to where the resident is located in their room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to monitor and record weights for a resident at risk for weight loss for 1 of 9 residents (R146) reviewed for weight loss in the sample of 35. Residents Affected - Few The findings include: R146's current care plan showed R146 was at risk for weight loss due to her diagnoses of dementia and depression. The plan showed R146's weight loss care plan/focus area was initiated on 8/12/22. The plan showed, Weigh the resident monthly or per facility protocol. The care plan showed no documentation of R146 refusing monthly weights prior to 11/17/23. R146's Weights and Vitals Summary record printed 12/5/23 showed R146 weighed 114 pounds (lbs.) on 7/2/23 and 101 lbs. on 8/26/23. The record showed no weight for R146 in August 2023 prior, to the weight documented on 8/26/23. This record showed R146 sustained a significant weight loss of 11.4% in 7 weeks. R146's discharge hospital record dated 8/21/23 showed R146 weighed 47.6 kilograms (104.7 lbs.). The record showed R146 was admitted to a local hospital, on 8/20/23, with diagnoses of diarrhea, syncope, and low blood pressure. R146's weights of 114 lbs. (on 7/2/23) and 104.7 lbs. (on 8/21/23) showed R146 sustained a significant weight loss of 8.2% in 6 weeks. On 12/5/23 at 1:00 PM, V7 Registered Dietician (RD) stated, (R146) was at risk for weight loss. Nutritional assessments were completed on (R146), by the dietary techs, in April 2023 and July 2023 that showed no significant weight loss. Those assessments showed the only interventions in place for her were for staff to monitor her intake and do monthly weights. As of July 2023, she wasn't on any supplements. I did not see her until 8/26/23, after her significant weight loss. We started her on supplements at that time. I can't tell you exactly what caused her weight loss or when it happened, because she was hospitalized the end of August (2023) . On 12/5/23 at 1:57 PM, V8 Dietary Technician stated R146 was at risk for weight loss. V8 stated, She should have been weighed by August 5th (2023). I am not sure why she wasn't weighed in August until after she got back from the hospital. R146's progress notes and assessments dated 7/2/23-8/20/23 were reviewed and showed no documentation R146 refused to be weighed by staff. The facility's Clinical Nutrition Documentation policy dated 4/2017 showed, Weights will be obtained upon admission, readmission to facility, then weekly x 4 weeks, then monthly unless otherwise ordered .Monthly weights are to be obtained no later than the 5th of each month with re-weights obtained by the 7th. The policy defined significant weight loss as a 5% loss in one month, 7.5% in three months, and 10% loss in six months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review the facility failed to ensure unqualified staff did not operate a resident's enteral (tube) feeding pump for 1 of 6 residents (R154) reviewed for tube feeding management in the sample of 35. The findings include: R154's current care plan showed R154 had a gastrostomy tube in place and required enteral (tube) feedings for adequate nutrition and hydration. The care plan showed a nurse was responsible for turning the feeding pump off prior to resuming the infusion once cares were completed. The plan showed, The feeding tube will be utilized in compliance with current clinical standards of practice and services provided to prevent complications to the extent possible for the resident. On 12/4/23 at 9:46 AM, R154 was in bed. An enteral feeding pump was noted on a pole next to her bed. The pump was on, infusing enteral feeding via R154's gastrostomy tube, at 60 ml (milliliters) per hour. On 12/4/23 at 10:26 AM, V5 and V6 Certified Nursing Assistants (CNA) entered R154's room to provide cares. V5 CNA walked over to R154's feeding pump and stopped R154's enteral feeding infusion. V5 and V6 CNA provided incontinence care to R154. Upon completion of cares, V5 CNA restarted R154's enteral feeding infusion via the feeding pump. On 12/4/23 at 12:35 PM, V4 Licensed Practical Nurse stated CNA's are not allowed to operate a resident's enteral feeding pump because they don't know how to run the pump. On 12/5/23 at 10:40 AM, V2 Director of Nursing stated, CNA's can't operate feeding pumps. They are not licensed to do so. They don't know how to run the pump. They don't know the settings of the pump. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Based on interview and record review the facility failed to ensure the Health Care Worker Registry was checked prior to hire to determine work eligibility for Certified Nursing Assistants (CNAs). This failure has the potential to affect all 183 residents residing in the facility. The findings include: The Center for Medicaid and Medicare Services (CMS-671) form completed by the facility on 12/4/23 shows the facility census was 183. On 12/6/23 at 8:32 AM, V19 (HR Director) said she was off work for a couple weeks recently and was not able to do the background checks which included the Healthcare worker registry check prior to hire for V21 and V22. V19 said the registry check for CNAs should be completed prior to hire as this determines work eligibility. Facility provided background checks for new hires show: V22 (CNA) was hired on 11/13/23 and the Healthcare Worker Registry was not checked until 11/21/23. V21 (CNA) was hired on 11/16/23 and the Healthcare Worker Registry was not checked until 11/21/23. On 12/6/23 at 10:30 AM, V19 checked in the computer system and verified that V22 started employment and worked her first day as a CNA on 11/13/23. V21 started employment and worked her first day as a CNA on 11/6/23 not 11/16/23 as her employee file had indicated. On 12/6/23 at 11:10 AM, V20 (HR Consultant) said Healthcare Worker Registry checks for CNAs have to be conducted prior to hire and then printed out to show a stamped date when the check was run. The facility provided not date Employee Background Checks policy says an individual employment is contingent on the successful passing of a background check. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 perform hand hygiene and change gloves during incontinence care to prevent cross contamination for 1 of 35 residents (R163) reviewed for infection control in the sample of 35. Residents Affected - Few The findings include: On 12/04/23 at 10:31 AM, V15, Certified Nursing Assistant (CNA), was providing incontinence care to R163. V15 used gloved hands to wipe stool from R163's frontal peri area then V15 rolled R163 to his right side and wiped his backside. V15 took the bottle of peri wash and sprayed R163's behind, removed his gloves and left the room (presumably to get more wipes). V15 did not perform hand hygiene before leaving or reentering R163's room. When V15 returned, he applied clean gloves and finished wiping the stool from R163's back side. Then using the same gloves, V15 rolled a clean pad and brief under R163. V15 removed the soiled pad and set it on the floor. V15 took the sheet and put it in a plastic bag with the pad then put a clean sheet over R163, adjusted his pillow and pulled him up in bed all with the same gloved hands. On 12/6/23 at 10:32 AM, V13, CNA, said when changing an incontinent resident she uses gloved hands, wipes the front area, changes gloves, wipes the back area, changes gloves, then puts the new brief and pad in place to prevent cross contamination. The facility's Guidelines for Incontinence Care Policy (dated 9/21/23) shows if feces are present, remove with a disposable wipe, discard the soiled materials and gloves, perform hand hygiene, apply clean gloves, remove linen or under pad and discard properly, remove and discard gloves, perform hand hygiene, apply clean linen/brief, then reposition the resident for comfort. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 10 of 10