Health inspection·March 22, 2024

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 implement appropriate infection prevention and control practices during medication administration by failure to disinfect medical equipment such as blood pressure (BP) apparatus and oximeter after each resident use. This deficiency affects all four (R65, R82, R124 and R150) residents in the sample of 35 reviewed for infection control during Medication Administration. Residents Affected - Some Findings include: On 3/19/2024 at 10:54AM, V12, RN (Registered Nurse), said she will take vital signs of R150 before giving his medications. V12 placed the BP cuff to R150's left arm and pulse oximeter on left index finger. V12 obtained BP 129/81mmhg (millimeter of mercury) and Oxygen (O2) saturation of 97%. V12 did not disinfect medical equipment (BP cuff and oximeter) used with R150 and prepared his medications. On 3/19/24 at 11:10AM, V12, RN, said that she will take vital signs of R124 before giving her medications. Without disinfecting the medical equipment used from another resident, V12 placed the BP cuff on R124's right arm and placed the pulse oximeter on right index finger. V12 obtained BP 128/76mmhg and O2 saturation of 95%. V12 did not disinfect medical equipment used with R124 and prepared her medications. On 3/19/24 at 11:34AM, R65 requested V12, RN, to take her vital signs. V12 took the same medical equipment, without disinfecting it. V12 placed the BP cuff to R65's left arm and pulse oximeter on left index finger. V12 obtained BP112/66mmhg and O2 saturation of 99%. V12, RN, did not disinfect the medical equipment after using it. On 3/19/24 at 11:38AM, V12, RN, said she will take R82's vital signs before giving her medications. V12 took the same medical equipment, without disinfecting it. V12 placed BP cuff around right arm and pulse oximeter on right index finger. V12 obtained BP 125/83mmhg and O2 saturation of 96%. V12 did not disinfect the medical equipment with R82 and prepared her medications. On 3/19/24 at 12:05PM, V12 said she should disinfect the BP cuff and pulse oximeter after each resident. V12 said she just forgot to disinfect it. On 3/19/24 at 12:35PM, V6, Infection Control Coordinator, said medical equipment such as BP cuff and pulse oximeter should be disinfected after each resident use. V6 added, It is a must to clean it, to prevent spread of infection. Facility's policy on Cleaning and Disinfection of Resident-Care Items and Equipment indicates: Page 1 of 2 145382 145382 03/22/2024 Lee Manor 1301 Lee Street Des Plaines, IL 60018

F 0880 Level of Harm - Minimal harm or potential for actual harm Policy statement: Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Center for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) bloodborne Pathogens Standard. Residents Affected - Some Policy Interpretation and Implementation: 1. The following categories are used to distinguish the level of sterilization/disinfection necessary for items used in resident care: c. non-critical resident care items are those that come in contact with intact skin, but not mucous membranes include blood pressure cuffs 3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 7. Intermediate and low-level disinfections for non-critical items include: a. Ethyl or isopropyl alcohol b. Sodium hydrochloride (5.25-6.15% diluted 1:500 or per manufacturer's instructions c. Phenolic germicidal detergents d. Iodophor germicidal detergents and e. Quaternary ammonium germicidal detergents (low level disinfection 145382 Page 2 of 2