Inspection·September 5, 2023

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 ensure that hand soap is always available for hand washing. In addition, the facility also failed to follow standard infection control practices related to hand hygiene and gloving during provisions of wound care. Residents Affected - Some This applies to 6 residents (R1, R3, R4, R5, R6, R7) reviewed for infection control in the sample of 7. The findings include: 1. On 8/24/23, there was an outbreak of Covid-19 in the memory care unit of the facility. The same day, from 9:23 AM through 11:15 AM, an environmental round was conducted to observe for availability of infection control supplies (personal protective equipment, and hand soap) in the memory care unit. It was noted that R1's, R4's, R5's, R6's, and R7's bathroom had no hand soap. There was no hand soap in the unit (memory care) hallway's bathroom used by visitors and staff. On 8/24/23 at 11:05 AM, R1 removed her right sock and showed her right foot which had a wound dressing on the big toe. Afterwards, R1 went to the bathroom to wash her hands and stated there was no soap in the soap dispenser. 2. Face sheet showed that R3 was 97 years-old who has multiple medical diagnoses which includes stage 4 pressure ulcer in the sacral region, and history of Covid-19 with acute respiratory distress. On 8/28/23 at 12:55 PM, V5 (Wound Care Nurse) provided wound care to R3. R3's wound dressing was heavily soiled. V5 cleansed R3's sacral wound, then she (V5) applied treatment, and covered the wound with dressing. V5 changed her gloves in between tasks. However, V5 did not perform hand hygiene, in between changing gloves from dirty to clean tasks. 3. Face sheet showed that R1 was 64 years-old who has multiple medical diagnoses which include history of Covid-19, and type 2 diabetes mellitus with foot ulcer. R1 also had history of MRSA (Methicillin-resistant Staphylococcus Aureus) on the right wound based on her progress notes of 3/28/23. On 8/28/23, R1 was in her bedroom and on contact and droplet isolation related to Covid. The same day at 1:11PM, V5 provided wound care to R1's diabetic ulcer on the right foot. V5 cleansed wound with NSS, applied treatment, and covered the wound with dry bordered gauze, while wearing the same gloves. R1's progress note dated 8/28/23 showed: R1 is on contact/droplet isolation related to being COVID-19. 4. Face sheet showed that R4 was 86 years-old who has multiple medical diagnoses which includes history of corona virus. Facility wound summary report showed that R4 has venous ulcer on the right calf, and pressure ulcer on the lateral aspect of the right foot. On 8/28/23 at 1:34 PM, R4 was resting in bed and was on isolation due to being positive for Covid-19. V5 provided wound care to R4. V5 changed R4's wound dressing on the right calf and lateral aspect of the right foot. V5 cleansed the wound, she applied treatment and cover the wound on the right foot. While wearing same gloves, V5 proceeded to do the wound care on the right calf. V5 cleansed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 2 of 3 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 wound, applied treatment, and covered the wound with dry dressing. V5 wore same set of gloves all throughout both wound cares. On 8/28/23 at 12:00 PM, V10 (Infection Control Staff) stated that the hand soap should be available in the all the soap dispensers for hand hygiene. Residents Affected - Some On 8/28/23 at 2:06 PM, V2 (Director of Nursing/DON) stated she expects the staff to perform hand hygiene before and after providing care, and between dirty to clean task. They should also change gloves and perform hand hygiene in between and/or before donning new gloves, this is to prevent spread of infection. Hand soap should always be available for hand hygiene as part of infection control measures. On 8/29/23 at 1:29 PM, V8 (Wound Care Doctor) stated it is important to change gloves and do proper hand hygiene during wound care to prevent infection. On 8/30/23 at 9:10 AM, V3 (Assistant Director of Nursing/ADN) when doing wound care, the staff must perform hand hygiene and change gloves in between task to prevent potential infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 3 of 3