Inspection·November 10, 2021

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 observation, interview and record review, the facility failed to follow standard professional practices by not implementing its policy and practices for hand hygiene and gloves usage during medication administration and wound care. Residents Affected - Some This applies to 4 of 7 residents (R6, R67, R68 and R166) reviewed for quality of care during wound care and medication administration in a total sample of 8. The findings include 1. On 11/07/21 at 12:14 P.M., V17 (RN/Registered Nurse) administered 2 units of Insulin subcutaneously via injection into R68's right side of the abdominal area. Prior to administering the insulin injection, V17 did not perform hand hygiene, and proceeded to touch computer keys, then lifted R68's shirt and injected the Insulin. V17 also did not don gloves prior to injecting the insulin. On 11/07/2021 at 3:33 P.M., V5 (Director of Nursing) stated that they do not have policy for donning on gloves when injection was provided. However, the expectation and standard of practice to ensure infection control was for the nurse/staff to perform hand hygiene and don on gloves prior to injection due to a risk for contact exposure of bodily fluids. The H&P (History and Physical) dated 11/4/2021 shows that R68, an [AGE] year old with diagnoses of diabetes mellitus, melanoma, fall on 10/29/2021 and sustained fractures to the lumbar 1 and 4 area. 2. On 11/08/21 from 8:45 A.M. to 9:43 A.M., medications were administered to R166 by V16 (RN/ Registered Nurse). The following were the medications that were administered: Baclofen 10 mg. 1 tab., Vasotec 10 mg. 1/2 tab., Vitamin D 50, 000 units, Vitamin E 400 mg. 1 tab., and Magnesium oxide 400 mg. 1 tab. In between medication administration, V16 informed R166 that she will apply the Bactroban ointment to R166's buttocks area. R166 pulled down his pants with V16's assistance. Then V16's stated I have to get gauze to clean the buttocks area before applying the Bactroban. V16 left the room and took the gauze from the nursing station, then R166 said I am going to therapy in few minutes, I just want my Tylenol and the medication for blood clot (Eloquis), will take shower after therapy then you can apply the cream (Bactroban). V16 washed hands at R166's bathroom hand sink and then turned off the water from faucet with bare hands and did not use a paper towel for creating a barrier to prevent cross contamination, and proceeded to administer R166's Tylenol 2 tablets. The H&P (History and Physical) dated 11/3/2021 shows that R166, a [AGE] year old with PMH (Past Medical History) of HIV (Human Immunodeficiency Virus), OSA (Obstructive Sleep Apnea), hyperlipidemia, hypertension, severe lumbar stenosis of lumbar 3 and 4, and had undergone discectomy on 10/16/2021. (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 6 Event ID: 145526 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 145526 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gottlieb Memorial Hospital 701 West North Avenue Melrose Park, IL 60160 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)