Health inspection·July 9, 2025

F 0880 Provide and implement an infection prevention and control program. 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 ensure that resident care equipment was clean and in good, repaired condition and properly stored by not comingling with functional ones to prevent accidental use for prevention of infection. This failure has the potential to affect R1, R3, R4, R5 and R6 reviewed for infection control. Findings include: R1's medical record admission record showed documentation that R1 was last admitted to the facility on [DATE] and listed diagnosis includes but not limited to Spastic quadriplegic cerebral palsy, spondylolysis lumbar region, type 2 diabetes mellitus with other circulatory complications, unspecified symptoms and signs involving cognitive functions and awareness, contracture of muscle, contracture of right wrist, joint disorder, contracture of muscle right hand, and low back pain.On 07/03/25 at 9:45am, V3 stated that (R1) and (R3) uses the shower device but R1 family member (V13) left instruction not to use the device until the bed pad is changed. V3 stated that the bed mat has holes in it but during shower we cover it with shower blankets before we put the residents on it. V3 showed the surveyor the blanket from the linen cart in the hallway. The surveyor asked V3 who is responsible for cleaning the shower bed device, V3 said the housekeepers are the ones that clean the shower device.On 07/03/25 at 9:48am, shower bed observed in the shower room with multiple holes on top and bottom (both sides) of the bed pad with brownish black colored particles. V3 CNA (Certified Nurses Aid) who was present during the observation said that was why V13 (family) did not want us (staff) to put R1 on it during shower, therefore R1 only gets a bed bath currently. V3 stated that the tears and stains have been on the bed pad for some time now and all we (staff) can do is to cover it with towels or blankets. When V3 was asked what can happen to residents using the device if not properly cleaned and in this condition. V3 stated that it looks like fungus, which can cause infection for the residents using it.On 07/03/25 at 10:08am, when this was shown to V7 RN (Registered Nurse). V7 stated that the anything (Equipment) used by the residents should be clean and in good condition it should not be torn like that (referring to the pad on the shower device). When the surveyor asked whether any of the staff has complained about it and made V7 aware about the condition of the device. V7 stated that I have only be working here almost one month now and I was not aware it was that bad. V7 was asked what can happen to residents using the device if not properly cleaned. V7 stated that it looks like molds or bacteria, and this can cause infection for anyone using it.At 10:12am, when V10 (Housekeeper) who was present at the time was asked about who is responsible for cleaning the shower device, V8 stated the CNAs are to make sure it is cleaned before and after use.At 10:16am, V8 (CNA) stated that the bed pad holes should not be left like that, and the brownish black stains does not show that the bed pad is clean. When the surveyor asked how long the shower assistive device has been like that. V8 stated I can't tell you how long, but it has been a while now.On 07/03/25 at 10:23am, V1 (Administrator) was shown the bed pad on the shower device, V1 stated that it must be V13 who complained because V13 was taking another resident's picture in the shower during shower on the Residents Affected - Some Page 1 of 2 145660 145660 07/09/2025 Aperion Care Westchester 2901 South Wolf Road Westchester, IL 60154

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some device. V1 stated in part that V13 was not satisfied with the one the facility bought. V1 could not produce any new bed pad bought when asked to. The surveyor asked V1 that even after the condition of the shower bed pad was shown to you still feel that the complaint is not warranted. V1 said that the device should not be used from now, I have ordered new bed pad. We just don't have anywhere to store it that was why it was stored in the shower room. You just don't throw it in the garbage. The surveyor inquired about the possibility of staff using it because it was not removed from the shower room and what can happen to the residents when common devices like the shower pad on the devices is used on multiple residents, V1 said no residents have skin rash or any infection yet. V1 stated the pad should have been removed from the premises, out of the shower room.On 07/03/25 at 11:47am, R3 observed in bed with V3 assisting in rendering bed bath. R3 asked V3 why he is getting bathed in the bed. V3 said I don't know why and continue with the bed bath. R3 said I could have gotten up to go and get the shower in the shower room (indicating that R3 prefer using the shower room). R3 turned to the surveyor and said I guess I will have to get the bed bath but getting the water all over is better. R3 said they put me on the shower bed. V3 then said R3 opted for the bed bath. On 07/03/25 at 11:59am, V13 (family) said about five months ago she noticed the rip on the bed bath pad, I did not turn it over then to see how damage it was. They (referring to staff) have not cleaned the fecal matter on the pad this was reported to their supervisor, and nothing was done. Then about a (one) month ago I reported, when nothing is done. Yesterday (07/02/25), I talked to (V1) and showed her the videos that I have taken. V13 said my son (referring to R1) is bedridden cannot shower himself, all I asked is for the bed pad to be changed. The last time, I was there during his shower I had to asked them to cover the bed pad with a plastic garbage bag because other residents use this, and I don't want my son to get infected. They (staff) did not cover it; they want to use a cloth to cover, and I think those things can seep through clothes. V13 said I have told them not to use shower bed for R1 until the bed pad is replaced. On 07/03 at 1:50pm, both V1 and V2 ADON (Assistant Director of Nurses) presented a list of residents that uses the shower bed (R1, R3, R4, R5 & R6). V2 said right now no one will use the bed bath device.Facility policy on Resident Rights presented with revised date 1/14/19 documented that the purpose of the policy is to promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limited in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability.The facility policy on Infection Prevention and Control Program presented with revision date 11/28/17 documented that the purpose of the policy is to comply with a system for preventing, identifying, reporting, investigating and controlling, infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. Listed guidelines include but not limited to the facility shall assure that necessary equipment and supplies are maintained to carry out an infection control program.Facility policy on Bathing: Complete bed bath with revision date 1/31/18 documented that the purpose of this policy is to ensure resident's cleanliness to maintain proper hygiene and dignity. Listed guidelines includes but not limited to shower will be offered according to resident's preferences. 145660 Page 2 of 2