Health inspection·February 20, 2025

F 0880 Provide and implement an infection prevention and control program. 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 staff failed to perform hand hygiene, and did not use PPE (Personal Protective Equipment) while providing care for residents in EBP (Enhanced Barrier Precautions) and failed to educate visitors regarding contact TBP (Transmission Based Precautions). Residents Affected - Some This applies to 7 of 7 residents (R2, R3, R4, R7, R8, R9, R10) reviewed for infection control practices in the sample of 10. The findings include: 1. R2's medical record showed R2 was admitted to the facility on [DATE], with multiple diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, chronic obstructive pulmonary disease, dysphagia, gastrostomy status, diabetes mellitus with chronic kidney disease, paroxysmal atrial fibrillation, and major depressive disorder, recurrent. R2's MDS (Minimum Data Set) dated February 9, 2025, showed R2 was cognitively intact and required assistance with ADLs including moderate assistance with oral hygiene, personal hygiene, upper body dressing and bed mobility, substantial assistance with coming to a sitting position in bed, with chair to bed and tub transfer and lower body dressing, and dependent on staff for eating and toilet hygiene. R2's care plans were reviewed. R2 has a care plan initiated on August 6, 2024, is at a higher risk for infection secondary to feeding tube and indwelling foley catheter and will receive enhanced barrier precautions with interventions that included, wash hands before entering and leaving the room and wearing PPE during high contact activity including changing linen, dressing, and bathing. On February 18, 2025, at 2:54 PM, there was a sign on R2's door for EBP, Enhanced Barrier Precautions. R2 stated she wanted to be repositioned because the sun was in her eyes. V10 (RN) entered the room to assist the resident to reposition without donning a gown and repositioned R2. R2's physician order summary showed R2 had an order for Enhanced Barrier Precautions initiated on July 1, 2024. 2. The medical record showed R3 was admitted to the facility on [DATE], with multiple diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, dysphagia, acute and chronic respiratory failure with hypoxia, tracheostomy status, gastrostomy status, and moderate protein-calorie malnutrition. R3's MDS dated [DATE], showed R3 was severely cognitively impaired, and required assistance with ADLs, including substantial assistance with oral hygiene and upper body dressing and dependent on staff eating, bathing, toileting, lower body dressing, bed mobility and transfer. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 145358 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 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)