Health inspection·November 15, 2024

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the antibiotic prescribed include duration, care plan, and documentation of long term used. This deficiency has the potential to affect 1 of 2 residents (R103) reviewed for antibiotic use in a sample of 23. Residents Affected - Few Findings Include: On 11/12/2024 at 12:31PM, R103 on Enhanced Barrier Precaution (EBP). R103 said he takes medication for infection. On 11/14/2024 at 01:02PM, R103 said he knows he is on antibiotic medication for infection but does not know the name and has been taking it since he came to facility in September 2024. On 11/14/2024 at 10:35AM, V4 (Infection Control Nurse) said R103 is prescribed antibiotic, Metronidazole, should include a start and stop date along with indication for use. V4 said as part of Antibiotic Stewardship program, V4 review all antibiotic prescribed within a day or two of admission and communicate to the doctor if the duration is not indicated and document on resident medical records. V4 said the antibiotic prescribed for R103 on September admission should have a stop date. On 11/14/2024 at 10:58AM, V2 (Director of Nursing/DON) said all antibiotic should have a start and stop date along with indication for use. Doctor should be informed if duration is not indicated. R103 Metronidazole antibiotic should have a stop date and not indicated for long term used. On 11/14/2024 at 01:05PM, V14 (Licensed Practical Nurse/LPN) said she is a regular on the unit where R103 resides but do not give antibiotic to R103 on her shift. V14 reviewed physician order with Surveyor which include the Metronidazole antibiotic. V14 said there should have been a stop date for the antibiotic. admission Record: Diagnosis Information: Sepsis, Unspecified Organism Order Summary Report: Metronidazole Oral Tablet 500 MG (Metronidazole) Give 1 tablet by mouth every 12 hours for Bacterial Infection, Order date - 9/25/2024, Start date - 9/26/2024, no End date. Care Plan (Created on 11/14/2024) Focus: R103 is on Antibiotic Therapy r/t bacterial infection. Policy: Guideline: Antibiotic Stewardship Review Date: 2/2024 Page 1 of 4 145684 145684 11/15/2024 Aliya of Homewood 940 Maple Avenue Homewood, IL 60430

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Policy: It is the policy of . to maintain an Antibiotic Stewardship Program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. Components of the policy were developed by using evidence-based practice guidelines and are aligned with the Core Elements of Antibiotic Stewardship for Nursing homes, published by Centers for Disease Control and Prevention (CDC)(1), and State Operations Manual (Appendix PP): Guidance to Surveyor of Long Term Care Facilities, published by CMS (2). Prescribing record keeping: Dose, duration, route, and indication of every antibiotic prescription MUST be documented in the medical record for every resident. Records will be reviewed monthly to assess compliance with this requirement, as well as prescription appropriateness for the individual resident. 145684 Page 2 of 4 145684 11/15/2024 Aliya of Homewood 940 Maple Avenue Homewood, IL 60430

F 0881 Implement a program that monitors antibiotic use. 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 implement ongoing monitoring of antibiotics. This deficiency affects one (R103) of three residents in the sample of 23 reviewed for Antibiotic Stewardship Program. Residents Affected - Few Findings include: On 11/14/2024 at 10:36AM, V4 (Infection Preventionist) said that she reviews the antibiotic medications prescribed weekly and an infection assessment evaluation is done prior to the start of antibiotic use for the purpose of monitoring for the antibiotic stewardship program. V4 said that R103 is currently on Metronidazole 500mg every 12hours for bacterial infection with no stop date. V4 said she is unable to locate R103's infection assessment evaluation record upon start of antibiotic. On 11/14/24 at 1:58PM, V2 (Director of Nursing) said that her expectations for the antibiotic stewardship program should be an ongoing monitoring of antibiotics. R013 admitted on [DATE] with diagnosis listed in part but not limited to sepsis unspecified organism, periprosthetic fracture around internal prosthetic left knee joint, subsequent encounter. Active physician order sheet indicates: Metronidazole tablet 500 MG every 12 hours for bacterial infection started on 9/26/24. Facility's policy on Antibiotic Stewardship Program indicates: Reviewed 2/2024. It is the policy of . to maintain an Antibiotic Stewardship Program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. Components of the policy were developed by using evidence-based practice guidelines and are aligned with the Core Elements of Antibiotic Stewardship for Nursing Homes, published by Centers for Disease Control and Prevention (CDC) (1), and the State Operations Manual (Appendix PP): Guidance to Surveyors of Long-Term Care Facilities, published by CMS (2). Actions Prescribing and record keeping. -Dose, duration, route, and indication of every antibiotic prescription MUST be documented in the medical record for every resident, regardless of prior prescriptions or documentation elsewhere (e.g., in medical record of a discharging facility). Notation of this information should be made on the day that an in-house prescription is written or on the day that a resident returns to the facility on an antibiotic prescribed elsewhere. -When a new antibiotic is prescribed, the receiving nurse will open a new case in the PCC Infection Control module and an Antibiotic therapy form in PCC. -Records will be reviewed monthly to assess compliance with this requirement, as well as prescription appropriateness for the individual resident, site, and type of infection. -Assessment of residents suspected of having an infection. Providers will utilize the McGeer's 145684 Page 3 of 4 145684 11/15/2024 Aliya of Homewood 940 Maple Avenue Homewood, IL 60430

F 0881 Criteria or the Loeb Criteria for initiating Antibiotic usage. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145684 Page 4 of 4