Health inspection·December 13, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to follow their policy in ensuring that a urinary catheter drainage bag was placed in a privacy bag for one (R106) of three residents reviewed for dignity in a sample of 24. Findings include: R106's diagnosis include but not limited to benign prostatic hyperplasia without lower urinary tract symptoms, chronic heart failure, and retention of urine. On 12/10/24 11:44 AM - R106 was observed with V16 (LPN/Licensed Practical Nurse). R106 has a roommate who was lying on bed 1. R106 was lying on bed 2 by the window. R106's urinary catheter drainage bag was not placed in a privacy bag and was in view to anyone that enters the room. On 12/10/2924 at 11:45 AM, V16 said that the CNA (Certified Nurses Assistant) must have placed the drainage bag in view instead of moving it to the window side where it could have been out of view. V16 said that the drainage bag should have been placed in a privacy bag or placed by the window. On 12/11/2024 at 1:30 PM, V2 (Director of Nursing) said that the urinary catheter drainage bag should be in placed a privacy bag. Facility Policy: Urinary Catheter Revised Date: 2 - 14 - 19 Purpose: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Guidelines 7. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly. May place drainage bag and excess tubing in a secondary vinyl bag or other similar device to prevent primary contact with floor or other surfaces. Page 1 of 5 145671 145671 12/13/2024 Elevate Care South Holland 16300 Wausau Street South Holland, IL 60473

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review the facility failed to ensure enteral (tube) feeding was administered according to physician order. This deficient practice has the potential to affect 1 of 2 residents (R37) reviewed for enteral management and administration in a sample of 24. Findings Include: During facility observation round, on 12/10/2024 at 11:25 AM, R37's tube feeding was hanging but was not connected or turned on as ordered. V9 (Licensed Practical Nurse/LPN) stated the physician order states for the tube feeding to be on at 9AM and feeding should have been turned on. On 12/11/2024 at 10:56 AM, V2 (Director of Nursing/DON) stated tube feeding should have been turned on according to physician's order. Nurses are expected to follow and carry out physician's order. admission Record: Diagnosis Information Encounter for Attention to Gastrostomy Order Summary: Enteral Feed Order every shift Nepro at 55ml (milliliters)/hour via pump x21 hrs/day Off @6am, On @ 9am/TOTAL DAILY: 1,155ml. Care Plan: R7 requires enteral feedings . Interventions: Enteral nutrition per physician order. Policy and Procedure: Policy Title: Medication Administration General Guidelines, no date Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). Procedures: Administration 2. Medications are administered in accordance with written orders of the prescriber. 145671 Page 2 of 5 145671 12/13/2024 Elevate Care South Holland 16300 Wausau Street South Holland, IL 60473

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the oxygen humidifier bottle was labeled with appropriate date. This deficient practice has the potential to affect 1 of 3 residents (R7) reviewed for Oxygen administration and management in a sample of 24. Residents Affected - Few Findings Include: During facility round observation on 12/10/2024 at 11:40 AM, R7 was using oxygen via nasal cannula with the portable concentrator and undated attached humidifier bottle. V14 (Licensed Practical Nurse/LPN) stated humidifier bottle should be labeled with the date so that staff will know when to change it. V14 said he will change the bottle and put the date on it. On 12/11/2024 at 11:00 AM, V2 (Director of Nursing/DON) stated oxygen humidifier bottle should be labeled with the date and changed once a week. admission Record: Diagnosis Information Chronic Obstructive Pulmonary Disease, unspecified; Acute Respiratory Failure with Hypoxia; Anxiety Disorder, unspecified Order Summary Report: Change Oxygen Tubing, Ear Protective Cushions, Humidifier Bottle, and plastic holding bag for oxygen tubing every night shift. Care Plan: Interventions: Oxygen per MD orders. Policy and Procedure Title: Care and Cleaning of Respiratory Equipment Policy: It is the policy of this facility that disposable respiratory equipment will be replaced on a schedule basis in order to minimize the risk of nosocomial infection. Procedure: VII. Labeling A. All disposable respiratory equipment is labeled with date when placed in use. X. Continuous aerosols A. Humidifier bottle is changed weekly and as needed. 145671 Page 3 of 5 145671 12/13/2024 Elevate Care South Holland 16300 Wausau Street South Holland, IL 60473

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 infection control practices, such as the use of personal protective equipment (PPE), was performed during blood glucose monitoring procedure. This deficient practice has the potential to affect 1 of 10 residents (R37) reviewed for use of PPE in a sample of 24. Residents Affected - Few Findings include: During observation on 12/10/2024 at 11:25 AM, V9 (Licensed Practical Nurse/LPN) entered R7's room, which displayed signage for Enhanced Barrier Precautions (EBP). V9 performed hand hygiene and put her gloves on then proceeded to the room without wearing the required PPE gown. V9 pricked R7's finger to perform blood glucose check, blood was visibly seen. After the procedure, V9 remove her gloves, performed hand hygiene then exited the room. V9 stated in EBP rooms the required PPE are gloves and gown. V9 said PPE gown should have been used while checking blood glucose. On 12/11/2024 at 11:00 AM, V2 (Director of Nursing/DON) stated in EBP rooms, the required PPE are gloves and gown, and hand hygiene should be performed. It is important to have the gloves and gown during blood glucose monitoring procedure for infection control. admission Record: Diagnosis Information Type 2 Diabetes Mellitus without Complications; Local Infection of the Skin and Subcutaneous Tissue, Unspecified Order Summary: Blood Glucose Monitoring: 4x/day Enhanced Barrier Precaution R/T Enteral Feeding, Trach, and Compromised Skin Integrity Care Plan: Enhanced Barrier Precaution: Wear gown and gloves Policy and Procedure Title: Enhanced Barrier Precautions (EBP), 1/15/2024 Purpose: To minimize the risk of acquiring, transmitting, or complications .Contact precautions would be warranted over EBP when there is risk of transmission of an actively infection agent. Guidelines: Staff will require the use of personal protective equipment (PPE) for high-risk activities such as: Any situation where expected contact of blood, bodily fluids, skin breakdown, or mucous membranes will be encountered. PPE required: 145671 Page 4 of 5 145671 12/13/2024 Elevate Care South Holland 16300 Wausau Street South Holland, IL 60473

F 0880 Gowns Level of Harm - Minimal harm or potential for actual harm Gloves Residents Affected - Few 145671 Page 5 of 5