Health 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. Page 1 of 6 145526 145526 11/10/2021 Gottlieb Memorial Hospital 701 West North Avenue Melrose Park, IL 60160

F 0684 Discussed infection control concerns with V4 (Administrator) and V5 on 11/08/21 at 10:45 A.M. Level of Harm - Minimal harm or potential for actual harm 3. The facility Weekly Pressure Ulcer log dated November 2021 showed that R67 was admitted with a stage 2 pressure ulcers to the left and right gluteal fold and the sacrum. The EHR (Electronic Health Record) showed a physician order to treat the pressure ulcers with Zinc oxide and cover the pressure ulcer with a foam dressing. Residents Affected - Some On 11/09/21 at 12:20 P.M., R67's pressure ulcer wound dressing was changed by V11 (Registered Nurse). V15 (CNA/ Certified Nurse Assistant) assisted V11. V11 donned a pair of gloves, proceeded to remove the soiled dressing from R67's sacrum/gluteal folds. The soiled dressing had a black substance on it. V11 continued to wipe R67's sacrum and the left and right gluteal folds using a moistened towelette. There were stage 2 pressure ulcers of R67's right and left gluteal fold and sacrum. After V11 wiped the sacrum and gluteal folds, V11 removed her soiled gloves, and donned a new pair of gloves. V11 failed to perform hand hygiene prior to donning a new pair of gloves. The H&P (History and Physical) dated 10/29/2021 shows that R67, [AGE] year old with diagnoses of weakness, leg edema and left leg DVT (deep vein thrombosis). On 11/09/21 at 12:25 PM, V5 (Director of Nursing) stated that it is the facility's practice to implement hand hygiene after removing soiled gloves and before donning a new pair of gloves during wound dressing changes when the soiled dressing was removed. 4. According to the Physician History and Physical dated 09/21/2021, R6 had diagnoses including hypertension, chronic obstructive pulmonary disease, status post right hip replacement with recent fall with a femur fracture, alcoholism, anemia, and heart disease. The Minimum Data Set (MDS) dated [DATE] showed R6 needed extensive assistance of two people for bed mobility, transfers, and toilet use. R6's cognition was intact. R6 had unhealed pressure ulcers and was at risk for developing pressure ulcers. The Physician Order Sheet (POS) showed R6 had an order for a coccyx dressing to clean with sterile saline, dry, apply medihoney, and cover with a sacral foam dressing change daily and as needed if soiled. On 11/08/21 at 1:44 PM, V14 (Registered Nurse/RN Wound Care) assisted V2 (RN) during wound care. V2 donned gloves and cleansed R6's wound using wound cleanser and gauze. Without changing gloves, V2 applied medihoney ointment to the wound using a wooden depressor, then placed a new foam dressing cover to the wound. V2 took a marker from her pocket to write the date on the dressing. On 11/09/21 at 12:55 PM, V5 (Director of Nursing/DON) said the nurse should change gloves and perform hand hygiene after the wound was cleaned and before applying the medication and dressing. V4 (Administrator) was present. The facility's Hand Hygiene policy dated 07/2019 includes to perform hand hygiene if moving from a contaminated body site to a clean body site during patient care. Review of the facility's policy for Handwashing with revision date of 7/2019 showed: II. a). Handwashing; c. Wet hands with running water. Apply soap thoroughly . Rinse hands thoroughly under running water. 145526 Page 2 of 6 145526 11/10/2021 Gottlieb Memorial Hospital 701 West North Avenue Melrose Park, IL 60160

F 0684 d) Paper towels should be use to dry hands. Paper towels should be used to turn off the water faucet. Level of Harm - Minimal harm or potential for actual harm The policy for hand hygiene also showed Perform hand hygiene before donning gloves and after removing gloves. Residents Affected - Some 145526 Page 3 of 6 145526 11/10/2021 Gottlieb Memorial Hospital 701 West North Avenue Melrose Park, IL 60160

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide food palatable for the resident. Residents Affected - Some This applies to 5 of 7 residents (R116, R6, R117, R118, R119) reviewed for food palatability in a total sample of 8 residents. The findings include: 1. On 1/07/21 at 10:06 AM, R116 said the Food tastes terrible. R116 said there weren't a lot of choices of food that taste good. 2. On 11/07/21 at 10:16 AM, R6 said the food did not taste very good and was very bland. On 11/08/21 at 02:21 PM, R6 said for lunch he had tomato soup and the macaroni and cheese. R6 said the macaroni and cheese didn't taste like anything, I'm not sure what kind of cheese it was supposed to be. R6 said he placed the macaroni and cheese into his tomato soup and was able to eat it that way. 3. On 11/07/21 at 11:32 AM, V12 (R117's family member-son) said he had asked for R117's food to be cut up before bringing it in to R117. V12 said the facility went to the extreme of putting R117's food through a blender and the taste of the food was very bland. V12 said even though the food was bland, R117 liked pasta and had enjoyed [NAME] the penne noodles onto the fork to eat. On 11/08/21 at 12:10 PM, V13 (R117's family member-wife) said R117 liked and ate all of the potato soup independently. R117 tried the pasta and said he didn't like it, No. This is no good. V13 tasted the pasta and said it was Ehh, it doesn't taste like much. On 11/09/21 at 12:09 PM, V13 (R117's family member) said he has the famous pasta for lunch today. The diet sheet showed R117 had a mechanical soft diet of penne pasta with marinara sauce and chopped green beans. 4. On 11/02/21 at 11:53 AM, R118 said the food was not good. R118 said the food was bland tasting and she was tired of seeing same bland food choices. 5. On 11/07/21 at 12:09 PM, R119 said she doesn't like the food here. R119 said she was a very finicky eater but she did not like the taste of the food at the facility. On 11/08/21 at 11:38 AM, a test tray was requested and the food was sampled. The macaroni pasta and cheese was a pale yellow with pale yellow liquid underneath. Both the macaroni and cheese and the corn were flavorless. The baked cod visibly looked moist and seasoned but when tasted, was dry and chewy. 145526 Page 4 of 6 145526 11/10/2021 Gottlieb Memorial Hospital 701 West North Avenue Melrose Park, IL 60160

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to perform deep cleaning to prevent pest infestation, maintain clean and sanitized foodservice equipment, store food in a manner that prevented contamination, utilize chemical sanitizing solution per manufacturer's instructions, and perform proper hand hygiene before/after touching food. This applies to all 15 residents receiving oral diets at the facility. The findings include: Facility document Alphabetical List of All Residents, dated 11/7/21, shows there were 15 residents in the facility. Facility document NPO (Not By Mouth) Patients, dated 11/7/21, shows there were no residents in the facility that had physician diet orders of NPO. 1. On 11/7/21 at 11:02 AM with V6 (Food Service Manager), a cockroach scurried out from behind the small steam-jacketed kettle equipment, turned around, and returned back underneath the equipment. There was a large amount of food debris located on the floor behind the small steam-jacketed kettle. The equipment did not have casters, was not movable, and the floor behind the equipment was not easily cleanable. V6 (Food Service Manager) stated she was aware that the pest control service was working to eradicate cockroaches recently in the kitchen. Pest control reports, dated 10/26/21, 10/27/21, 10/28/21, 10/29/21 and 11/5/21, show there was an accumulation of food crumb debris found under coolers of the cook production line creating a German roach harborage. The 1/26/21 report shows German cockroach activity was found in several areas of the kitchen. On 11/09/21 at 1:15 PM V20 (Regional Food Service Manager) stated there needed to be a greater effort to perform more deep cleaning in the kitchen. V20 stated the foodservice operation has experienced a chronic lack of staff and the operation has had to prioritize meal service. On 11/9/21 at 12:20 PM with V6, V19 (Director of Environmental, Transportation, and Linen) stated the roach problem has been a longstanding problem, especially in the facility kitchen. V19 stated the kitchen has been chemically treated three times a week by pest control for approximately a year. V19 stated there has consistently been a cleaning concern identified in the pest control reports regarding the facility kitchen. V19 stated the food service staff were responsible for the cleanliness of the kitchen. On 11/09/21 at 12:49 PM, V4 (Administrator) stated she was not aware of the ongoing concerns about roaches in the food service. 2. On 11/7/21 at 11:10 AM with V6, V7 (Cook) was setting up food on the tray line for lunch service. A red sanitation bucket with a white rag was sitting below the steam table on the shelf. V7 stated she was utilizing the sanitation bucket at her station while working on the tray line. V7 stated she changed the sanitizing solution in the sanitizing bucket approximately one hour prior and that the staff were expected to change the sanitizing solution in the sanitizer buckets every two hours. V6 145526 Page 5 of 6 145526 11/10/2021 Gottlieb Memorial Hospital 701 West North Avenue Melrose Park, IL 60160

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated the kitchen utilized quaternary ammonium in the sanitizing buckets to sanitize food service work areas. V6 checked the concentration of the sanitizing solution in the cook's sanitizing bucket which measured 0-100 ppm (parts per million) of quaternary ammonium. On 11/7/21 at 11:12 AM with V6, V7 emptied the sanitizing solution from the bucket in the mop room and refilled the sanitizing bucket with sanitizing solution which was premixed and dispensed from a wall dispenser. As the bucket was filled, none of the pink sanitizing solution was siphoned up through the tubing and into the dispenser from the sanitizing chemical bucket. When the bucket was filled, V6 checked the concentration of the liquid in the sanitizing bucket and the solution measured 0-100 PPM. Sanitizer Solution Log, undated, stated the required quaternary ammonium sanitizer solution concentration was 150-400 ppm. Facility Procedure Infection Prevention and Control Guidelines for Food and Nutrition Services, dated 9/2018, shows, D. Sanitizing Food Contact Equipment . 3. All food preparation areas and equipment that come into contact with foods will be washed, rinsed, and sanitized after each use, or after any interruption during which contamination could occur. 3. On 11/7/21 at 11:20 AM in the walk in cooler with V6, there were four cases of raw chicken breasts stored directly over a tray holding large tubes raw ground beef. V6 stated the raw chicken should be stored under the raw ground beef. Facility Procedure Receiving and Storage, October 2020, shows, Fresh meat must be stored in the following order from top to bottom: Ready-to-eat (top), Seafood, Whole cuts beef or pork, Ground meat and ground fish, Whole and ground poultry (bottom). 4. On 11/7/21 at 11:35 AM with V6, V8 (Cold Prep Cook) was using gloved hand to touch quesadillas while cutting and folding them after touching handles on food preparation drawers, utensils, countertops, plates, plate warmers, and without washing her hands or changing her gloves. V6 sated V8 should have changed her gloves and washed her hands before and after touching the quesadilla. Facility Procedure Infection Prevention and Control Guidelines for Food and Nutrition Services, dated 9/2018, shows, B Hand Hygiene 1. Hand hygiene shall be conducted in a timely manner before resuming food handling or duties in the kitchen . 2. Food shall be prepared with minimal manual contact. Colleague should use utensils, such as tongs, spatulas, and single use gloves. Colleague will not touch any foods with their bare hands 5. On 11/7/21 at 11:02 AM with V6, the can opener near the cold preparation area had a dark red substance dried around the blade of the can opener. In addition, a scoop was stored in the rice bin with the handle of the scoop embedded into the rice. V6 stated the scoop should not have been stored in the rice to prevent contamination. 145526 Page 6 of 6