Health inspection·April 4, 2024

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, interview, and record review the facility failed to follow their policy and procedure related to infection control by not wearing appropriate personal protective equipment (PPE) in resident rooms who required contact isolation and by not practicing hand hygiene while performing incontinence care for a resident. This failure applied to three of three (R82, R275, R277) residents reviewed during review of facility infection control practices. Residents Affected - Few Findings include: Per contact isolation log dated 04/2024, shows R275 on contact isolation for MRSA in the urine and R277 on contact isolation for VRE in the urine. 1.) On 4/1/24 at 1:20PM, V9 (Dialysis Social Worker) was observed entering R275's room not wearing any PPE. V9 sat on the edge of R275's bed next to R275 to have a discussion. 2.) On 4/2/24 at 12:40PM, V11 (Director of Rehab) was observed to be in R277's room not wearing a gown. V20 (family member) was also observed entering R277's room without putting on any PPE and without performing any hand hygiene. V20 was then observed leaving the room and going to the nursing station to speak with staff without performing any hand hygiene. On 4/2/24 at 1:40PM, V21 (Infection Preventionist) was interviewed regarding contact isolation expectations. V21 said my expectation is that prior to entering the room of any resident who is on contact isolation, no matter who it is: staff and visitors should perform hand hygiene with hand sanitizer and put on a gown and gloves. Prior to exiting the room, they are to take PPE off and perform hand hygiene. Family is informed of this when a resident is put on isolation and there is also a sign and PPE placed outside of the door for them to utilize. Policy titled Infection Prevention and Control with last revision date of 10/23/23 states in part but not limited to the following: 2. Contact Precaution- intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment. Use of gown and gloves is necessary prior to room entry. Residents are restricted to leave the room except for medically necessary procedures and appointments. 3.) R82 is a cognitively impaired [AGE] year-old resident with diagnosis listed in part, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, vascular dementia, and type II diabetes mellitus. On 04/03/2024 at 9:57am, V22 (Wound Care Coordinator) said R82 has poor appetite, does not eat Page 1 of 3 145701 145701 04/04/2024 Bella Terra Streamwood 815 East Irving Park Road Streamwood, IL 60107

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few through the mouth, is being fed via a g-tube, has low albumin levels, used to have pitting edema, which is now controlled, has moderate to severe atherosclerosis, venous insufficiency, and had sepsis that resolved with antibiotics. On 04/03/2024 at 12:15pm, surveyors observed perineal care done for R82 by V13 (Certified Nursing Assistant/CNA) and V14 (Restorative Aide). V13 and V14 donned gowns, gloves, and masks prior to entering R82's room. R82 was laying on an air mattress, which was covered by one sheet. R82 was moved toward the head of the bed by V13 and V14. The wound dressing on R82's sacrum was partially loose. R82's soiled brief was removed by V14 and thrown into a trash can. V14 placed a new disposable brief on R82 but left it open. V13 used cleansing wipes to clean R82's perineal area, then (petroleum jelly) was applied by V13 to R82's buttocks and the disposable brief was taped close. Surveyor observed every time V14 removed gloves while performing perineal care for R82 and noted that V14 did not perform hand hygiene before putting on new gloves. After the perineal care was completed, surveyor asked V14 to review the steps taken when performing perineal care for R82. V14 said, sorry for not performing hand hygiene between glove changes. V14 added that they did not have hand sanitizer at their disposal during R82's perineal care and was nervous. Per the facility's hand hygiene policy, dated 07/28/2023, hand hygiene using alcohol-based hand rub is highly recommended before and after direct resident contact, after performing an aseptic task, and before moving from work on a soiled body site to a clean body site on the same resident. Also, the policy states, the facility will comply with the CDC guidelines in regard to hand hygiene. Per CDC Website, Hand Hygiene in Healthcare Settings the following recommendations are: The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -Immediately before touching a patient -Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices -Before moving from work on a soiled body site to a clean body site on the same patient -After touching a patient or the patient ' s immediate environment -After contact with blood, body fluids, or contaminated surfaces -Immediately after glove removal Healthcare facilities should: -Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations 145701 Page 2 of 3 145701 04/04/2024 Bella Terra Streamwood 815 East Irving Park Road Streamwood, IL 60107

F 0880 -Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled Level of Harm - Minimal harm or potential for actual harm -Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered Residents Affected - Few -Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands. 145701 Page 3 of 3