Health inspection·December 9, 2022

F 0677 stated he has a bed bath twice a week. Level of Harm - Minimal harm or potential for actual harm The MDS (Minimum Data Sheet) dated 10/2/2022 showed R49 requires extensive assist of two with dressing and personal hygiene. Residents Affected - Few R49 is not Care Planned for Self-Care Deficit. Shower sheets reviewed from 11/1/2022 to 11/28/2022. Shower sheets do not show if shaving was done. On 12/07/2022 at 10:00 AM V2 (DON- Director of Nursing) stated, residents are shaved and fingernails are cut after shower and as needed. V2 stated there is only one resident who refuses to be shaved in the facility. On 12/07/2022 at 11:04 AM V4 (RN- Registered Nurse) stated, if a resident is observed with long facial hair and/or long dirty fingernails, V4 informs the CNA (Certified Nursing Assistant). On 12/07/2022 at 11:11 AM V5 (CNA) stated that facial hair is shaved, and nails are cut after a shower and as needed. V5 stated he has no resident that refuses grooming like shaving and cutting of fingernails. On 12/08/2022 at 11:36 AM, V9 (ADON-Assistant Director of Nursing) stated staff is expected to complete grooming like shaving and nail cutting after shower. V9 stated she is not aware of where the documentation for grooming was. On 12/8/2022 at 12:09 PM, V2 stated there is no specific documentation in the facility to show shaving and cutting fingernails are done. The Facility's Fingernails/Toenails, Care of Policy and Procedure dated February 2018 shows the date and time of nail care should be recorded in the resident's medical record The Facility's Policy and Procedure on Shaving the Resident dated February 2018 shows the date and time of the procedure should be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145409 If continuation sheet Page 2 of 4 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 145409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Michaelsen Health Center 831 North Batavia Avenue Batavia, IL 60510 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 2. On 12/06/2022 at 11:56 AM, R35 said she soiled her incontinent pads and proceeded to use the call light to ask for help. V3 (CNA - Certified Nursing Assistant) answered call light. R35 said she needed incontinence care and V3 proceeded to provide care. V3 washed her hands and donned gloves. V3 unfastened soiled incontinent pads and wiped R35's perineal area from top to bottom. V3 proceeded to wipe R35's buttocks. V3 removed the soiled incontinent pads and threw it in the garbage can. Without changing gloves, V3 proceeded to apply new incontinent pads. Using same dirty gloves, V3 rearranged R35's clothing and pillows. After care, V3 proceeded to take her gloves off, gather all garbage and proceeded to go out of the room. V3 stated she should have changed her gloves after taking out soiled incontinent pads, disinfect hands and applied new gloves before applying new incontinent pads. V3 also stated that she should have disinfected her hand after taking off gloves. Residents Affected - Few On 12/07/2022 at 11:11 AM, V5 (CNA) said during incontinence care, if gloves are not soiled, he does not change gloves all throughout incontinence care. He stated that he only changes gloves if gloves are soiled. On 12/08/2022 at 12:09 PM, V2 (DON-Director of Nursing) said that it is expected for staff to take gloves off and sanitize hands after taking out soiled incontinence pads. V2 stated before applying new incontinence pads, staff should apply fresh clean gloves as part of infection control. 3. On 12/6/2022 at 11:50 AM during initial tour, R219 was noted in bed and had an indwelling catheter. R219's catheter drainage bag was noted on the floor by the bedside; the catheter drainage bag was not in a privacy bag. V5 CNA (Certified Nurse Aide) and V8 CNA came in room to reposition R219. V5 said R219's catheter bag should not be on the floor because it will not drain properly. On 12/7/2022 at 11:17 AM, V2 DON (Director of Nursing) said that catheter bags should be in a privacy bag and the catheter bag should not be on the floor due to infection control reasons. The facility's policy titled Catheter Care, Urinary (September 2014) under Infection Control, b. Be sure the catheter tubing and drainage bag are kept off the floor. Based on observation, interview, and record review, the facility failed to collect stool specimens to rule out C-Diff (Clostridium difficile) per physician's order. The facility also failed to maintain an indwelling catheter bag off the floor and change gloves during incontinent care while moving from dirty to clean. This applies to 3 of 3 residents (R2, R219, and R35) reviewed for resident care and infection control practice in a sample of 22 Findings include: 1. Record review of R2's Physician Order Sheet (POS) documents a physician order placed on 12/5/22 to collect stool to rule out C-Diff. On 12/7/2022 at 11:22 AM, during wound care by V9 (infection control nurse/wound care nurse) and V6 (Certified Nursing Assistant - CNA), R2 was observed with significant diarrhea. During the wound care, V6 commented that R2 was having frequent diarrhea and she had changed R2 in the early morning after six. V10 (Registered Nurse) was interviewed on 12/8/2022, at 1:15 PM. V10 stated that R2's stool was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145409 If continuation sheet Page 3 of 4 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 145409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Michaelsen Health Center 831 North Batavia Avenue Batavia, IL 60510 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete collected yet. V10 stated that she was endorsed to collect stool for C-Diff, and she doesn't know why they didn't collect stool as per the physician's order after multiple episodes of diarrhea with R2. V2 (Director of Nursing - DON) was interviewed on 12/8/2022, at 1:45 PM. V2 stated that her staff is still waiting to collect R2's stool specimen. V2 stated that it should have been collected earlier with previous episodes of diarrhea. Event ID: Facility ID: 145409 If continuation sheet Page 4 of 4