Inspection·June 9, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R56's Care Plan dated April 2, 2023, states R56 requires assistance with ADLs including personal hygiene and interventions including to assist R56 with bathing. R56's ADL- Bathing and Skin Monitoring task 30 day look back from June 8, 2023, shows R56 received 4 baths in the past 30 days. No bathing refusals have been documented in the past 30 days. 3. R7's MDS dated [DATE], shows R7 requires extensive assistance with personal hygiene including shaving. On June 6, 2023, at 10:46 AM and June 7, 2023 at 11:54 AM, R7 was observed with greasy hair with skin flakes in it and unkempt, different lengths facial hair. R7 said the frequency of bed baths varies. R7's Care Plan dated March 30, 2023, shows R7 requires extensive assistance with ADLs including personal hygiene/shaving related to history of stroke. Interventions include to assist R7 with bathing. R7's ADL-Bathing and Skin Monitoring task 30 day look back from June 8, 2023, shows that R7 received 1 bath in the past 30 days. No bathing refusals were documented in the last 30 days. 4. R61's MDS dated [DATE], shows R61 requires one-person physical assist with personal hygiene including shaving. On June 6, 2023, at 10:58 AM, R61 was observed with uneven, unkempt hair on his chin and upper lip. R61 said he requires assistance with shaving because he cannot lift his right arm to his face and his left hand is shaky. R61 said it was about two weeks since he was last shaved and he would like to be shaved at least once a week. R61's Care Plan dated June 8, 2023, shows R61 requires assistance with ADLs including personal hygiene/shaving related to generalized muscle weakness. On June 8, 2023, at 11:32 AM, V2 (DON/Director of Nursing) said resident showers/baths are scheduled twice a week and as needed if a resident wants a shower or bath on another day. V2 said shaving is done twice a week also, on shower days, and as needed. The facility's policy revised July 28, 2022, and titled, General Care states: Policy Statement: It is the facility's policy to provide care for every resident to meet their needs. Procedures: 1 Physical needs would include, but are not limited to ADL . The facility's policy revised July 28, 2022, and titled, Shower and Hygiene states: Policy Statement: It is the policy of this facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident . Procedures: 4. Nursing staff to provide bed bath daily and PRN as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 2 of 8 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 145711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Elmhurst 420 West Butterfield Road Elmhurst, IL 60126 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to properly secure medications; sign controlled substances count form and resident's narcotic sheet; have two nurses sign off on the narcotic sheet when wasting narcotic medication; remove expired medication and double-lock narcotic medication. This applies to 15 of 15 residents (R16, R25, R28, R29, R46, R50, R53, R54, R56, R58, R60, R63, R66, R71, R295) reviewed for medications. The findings include: On June 6, 2023, at 10:51 AM, V3 (RN/Registered Nurse) identified the residents who have medications in her medication cart. The following observations were made: 1. R46's medication card with Lacosamide 100 MG (Milligrams) had 11 tablets. It was compared to R46's controlled drug administration record which documents: Lacosamide 100 MG: Give 1 tablet by mouth twice daily. The form showed the medication card contained 12 tablets. V3 was questioned about the discrepancy. V3 replied, I wasted it (Lacosamide) with the other nurse (V5-RN) and put it into the sharps container. I forgot to sign it off on (R46's) form. Both of us didn't sign it off. I forgot. Both of us should have signed it off because we both wasted it together. 2. R63's medication card with Pregabalin 75 MG had 20 capsules. R63's controlled drug administration record form documents Pregabalin 75 MG: Take one capsule by mouth twice daily. It documents 20 capsules. R63 stated, Oh wait, that's not right. It's supposed to be 19. I gave one pill to her earlier. I forgot to sign it off. Yes, when we administer narcotics, we have to document both on the form in the binder and in the EMAR (Electronic Medication Administration Record). 3. R28's May POS (Physician Order Sheet) documents Humalog Kwik Pen subcutaneous solution pen-injector 100 units/ML (Milliliters) (Insulin Lispro)-Inject 3 units subcutaneously with meals for blood sugar. Inject into the skin three times daily with meals. Sliding scale. On June 6, 2023, at 11:02 AM, in V3's medication cart, R28's Insulin Lispro Kwik pen had an open date of April 29, 2023, with a written expiration date of May 26, 2023. R28's EMAR documents R28 was getting the expired insulin until June 6, 2023. V3 stated, This insulin pen has expired. I need to get a new one. On June 6, 2023, at 11:06 AM, the narcotic shift to shift inventory count binder for V3's medication cart was reviewed. The June Controlled Substances Count Form was not signed off by night nurse on June 1, 2023. It was not signed off by day nurse on June 2, 2023. It was also not signed off by day nurse on June 5, 2023. On June 6, 2023, V3 did not sign off in the day shift nurse on slot. V3 stated, I did count with the night nurse, but I forgot to sign for it. Yes, the nurses should both sign the form after doing the count together. V3's medication cart had narcotics for the following residents: 4. R25 had 7 tablets of Temazepam 7.5 MG capsule at bedtime, 20 capsules of Pregabalin 50mg capsules TID (Three Times a Day), 17 tablets of Hydrocodone-APAP 5-325 MG every 6 hours PRN (As Needed). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 3 of 8 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 145711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Elmhurst 420 West Butterfield Road Elmhurst, IL 60126 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 0761 5. R16 had 26 tablets of Alprazolam 1 MG at bedtime. Level of Harm - Minimal harm or potential for actual harm 6. R54 had 21 tablets of Hydrocodone-APAP 5-325 MG every 4 hours PRN for pain 7. R71 had 13 tablets of Tramadol 50 MG--1 tablet every 6 hours PRN. Residents Affected - Some 8. R28 had 2 tablets of Tramadol 50 MG--1 tablet every 6 hours PRN On June 6, 2023, at 12:01 PM, V6 (LPN/Licensed Practical Nurses) medication cart was inspected by surveyor in V6's presence. 9. R29 had a medication card with 10 tablets of Norco 5-325 MG. The expiration date was May 31, 2023. V6 stated, This is already expired and it should not belong here. I have to tell my supervisor. I will have to discard this with another nurse. On May 6, 2023, at 12:25 PM, surveyor went with V5 (RN) to the second floor medication room. The fridge inside had no lock on it. Inside the fridge, R295's Ativan 2 MG/ML (Lorazepam) Intensol oral concentrate was on top of the small side panel. There was a plastic kit which contained 2 bottles of Ativan 2 MG/ ML in a plastic box with a plastic tie. V5 stated it was house stock. V5 stated she did not know why the fridge did not have a lock on it. V5 said since she's been working here the medication fridge has never been locked. On June 7, 2023, at 10:11 AM, V2 (DON/Director of Nursing) stated, Insulin should be dated with both an open and expiration date because some insulins are specific. Some are good for 28, 30, or 42 days. My expectation is that during shift change, the nurses are to do the count together and both should sign the narcotic verification sheet then and there. After nurses administer narcotic medication to the residents, they are to sign it off on the residents' medication sheet in the narcotic binder and in the eMAR. When nurses have to waste medication, they have to do it together and they both have to sign off for it. Expired medications should be removed from the supply. Nurses need to check the expiration date before they administer medications. We will have the Ativan in the medication fridge in the medication room double-locked. 10. On June 6, 2023, at 10:15 AM, R50 was observed to have a cupful of medication by his bedside. R50 stated it was his morning medication and the nurse left it on his bedside table so he can take the medication when he wants to. R50 began to take the medication by himself. There were also two tubes of Voltaren cream on R50's nightstand. On June 6, 2023, at 11:16 AM, interview with V6 (LPN-Licensed Practical Nurse) stated V6 brought R50's medication in a cup. V6 (LPN) said she had to leave without administering the medication to R50 because she had to get a breathing treatment for another resident. V6 (LPN) stated she knew she cannot leave medication by the bedside and when she stepped out of R50's room, she should have taken the medication with her. V6 (LPN) said the medications in the cup were 1 tablet of Aspirin 81 mg (milligram), 2 tablets of Calcium 500 mg with Vitamin D, 1 tablet of Ferrous Sulfate 325 mg, 1 tablet of Cyanocobalamin 1000 mcg (microgram), 1 tablet of Hydralazine Hydrochloride 25 mg, 1 tablet of Losartan Potassium 50 mg, 2 tablets of Magnesium Oxide 400 mg, 1 tablet of Spironolactone 25 mg and 1 tablet of Tamsulosin Hydrochloride 0.4 mg. Review of R50's June POS (Physician Order Sheet) showed R50 did not have an order for Voltaren Arthritis pain gel and no order for medication to be stored at bedside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 4 of 8 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 145711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Elmhurst 420 West Butterfield Road Elmhurst, IL 60126 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 0761 Level of Harm - Minimal harm or potential for actual harm On June 8, 2023, at 09:41 AM, interview with V2 (DON-Director of Nursing) stated a nurse should not leave medication unattended. V2 (DON) stated V6 (LPN) should have finished administering the medication to R50 before attending to another resident. V2 (DON) stated there is no resident in the building with an order for medication at the bedside and no resident in the building with order to self-administer medication. V2 said all medication should have an order given by the doctor. Residents Affected - Some 11. On June 6, 2023, at 10:41 AM, Nystatin powder and Lotrimin Antifungal external aerosol 2% were observed on R53's nightstand. R53 stated staff applies the medication on him after incontinence care. R53 stated staff always leaves the medication on his nightstand. Review of R53's June POS showed R53 did not have an order for medication to be stored at bedside. 12. On June 6, 2023, at 10:49 AM, 'Icy Hot Pain Relief Roll On' medication was observed on R58's bedside table. R58 stated she applies it on her hands and legs. R58 stated her brother or his girlfriend brings the medication in to R58. Review of R58's June 2023 POS showed R58 did not have an order for 'Icy Hot Pain Relief Roll On'. R58 did not have an order for medication to be stored at bedside. 13. On June 6, 2023, at 11:15 AM, Diclofenac Sodium cream and [NAME] Phos 6x were observed on R66's bedside table. R66 stated she takes the [NAME] Phos 6x when she needs to. R66 was unable to say what she took the [NAME] Phos 6x for. R66 stated her family brought the supplement to her. Review of R66's June POS showed R66 did not have an order for [NAME] Phos 6x. R66 did not have an order for medication to be stored at bedside. 14. On June 6, 2023, at 11:43 AM A full bottle of Fluticasone Propionate 50mcg (microgram) nasal spray medication was found at the bedside of R60. R60 said, Why don't it come out for me? On June 7, 2023, at 11:41 AM the nasal spray was again seen on R60's bedside table. R60 said the last time she used the nasal spray was a few days ago. R60 said, there have been times she tried to use the nasal spray but it didn't come out and at first, she didn't know you had to take the top off. R60 said she doesn't sleep well at night because she is always up blowing her nose and she uses the nasal spray when her nose is stopped up. There is no order on the POS (Physician Order Sheet) showing that R60 can self-administer her Fluticasone Propionate nasal spray. There is no completed assessment that shows R60 is safe to self-administer medications. 15. On June 7, 2023, at 11:55 AM A bottle of Nystatin topical powder 100,000 units/gram was found on R56's bedside dresser. R56 says she gets the powder under her arms. There is no order on the POS showing that R56 is safe to have any medications at her bedside. On June 8, 2023, at 11:32 AM, V2 (DON) said there are no residents currently with a physician order to have medications at the bedside. V2 said R60 and R56 should not have any medications at their bedside. V2 said it is not safe because the facility needs to monitor the frequency the medications are being taken, expiration dates of medications, and assess residents' ability to safely self-administer medications. V2 said this is also a safety concern for other residents who wander and might enter the room of another resident where medications are accessible. Facility's policy titled Controlled Medications Count (July 27, 2022) documents: Procedure: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 5 of 8 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 145711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Elmhurst 420 West Butterfield Road Elmhurst, IL 60126 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. 2. After administration of the controlled medication, the nurse will sign off the eMAR. 3. If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication. Facility's policy titled Medication Pass (March 28, 2023) documents: Medication Labeling: 1. All opened medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening except for Levemir insulin which can be discarded 42 days after opening .2. Follow pharmacy recommendation as to when the medication should be discarded after opening. 3. Insulin vials are to be discarded within 28 days after opening, except for Levemir insulin which are to be discarded 42 days after opening. Controlled substances: 1. All scheduled 2 controlled substances will be stored properly and double locked. Facility's policy titled Medication Storage, Labeling, and Disposal (October 24, 2022) documents: 4. Medications will be secured in locked storage area. 5. Scheduled 2 medications will be double locked (example: placed in a locked medication cart inside a locked controlled medication box, placed in a refrigerator with 2 separate locks if the medication requires refrigeration, or placed in a locked medication room inside a locked refrigerator if the scheduled 2 medication requires refrigeration. Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The facility's policy revised July 28, 2022, and titled Self-Administration of Medication states Policy Statement: .A resident who requests to self-administer medications will be assessed to determine if resident is able to safely self-mediate. Procedures: . 2. The resident may store the medication at the bedside if there is a physician order to keep it at bedside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 6 of 8 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 145711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Elmhurst 420 West Butterfield Road Elmhurst, IL 60126 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 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 follow infection control procedures during medication administration, equipment cleaning, incontinence care, and while providing direct care of residents under EBP (Enhanced Barrier Precautions). This applies to 7 of 8 residents (R23, R31, R54, R59, R67, R95, R346) reviewed for infection control in a sample of 27. Residents Affected - Some Findings include: 1. On June 6, 2023, at 11:32 AM, V3 (RN/Registered Nurse) performed a blood glucose check on R54 in her room with a glucometer. V3 then took the glucometer to her medication cart. V3 removed her gloves and put on new gloves without performing hand hygiene and proceeded to sanitize the glucometer with bleach wipes. Facility's policy titled Glucose Meter Cleaning (July 28, 2022) documents: Procedures: 1. Wash hands thoroughly with soap and water or hand sanitizer before and after the procedure. 2. Wear clean gloves. 3. Place the equipment on a clean surface. 4. Clean and disinfect glucose meter with bleach wipes before after each use. 2. On June 7, 2023, at 8:03 AM, V4 (Agency RN) administered medications to R95 without performing hand hygiene prior to administration. Facility's policy titled Medication Administration General Guidelines (Unknown Date) documents: Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: a) before beginning a medication pass, b) prior to handling any medication, c) after coming into direct contact with a resident. 3. On June 7, 2023, at 8:41 AM, V5 (RN) put R67's medication onto a reusable medication tray. V5 went to R67's room and placed it on top of R67's bedside table. V5 then administered R67's medication. V5 then went back to her medication cart and put the medication tray under a tissue paper box without sanitizing it. On June 7, 2023, at 10:11 AM, V2 (DON/Director of Nursing) stated, Medication trays should be sanitized after use. Staff need to wash their hands or use hand sanitizer before and after medication administration. The nurse needs to sanitize her hands first, then put on new gloves and sanitize the glucometer. Facility was unable to provide a policy on cleaning medication trays. 4. On June 7, 2023, at 8:58 AM, V6 (LPN/Licensed Practical Nurse) administered medications to R23 without performing hand hygiene prior to administration. 5. On June 6, 2023, at 12:52 PM, R346 was in an EBP (Enhanced Barrier Precaution) room. EBP signage was posted on the door and isolation bin was outside room door. V11 (CNA) was observed inside room with gloves only on applying clean linen to bed. Dirty linen was observed in a bag on the floor. On June 8, 2023, at 9:15 AM, V2 (DON/Director of Nursing) said if staff are providing direct care, they need to wear a gown and gloves. V2 said the staff should be wearing a gown when taking the resident to the bathroom and changing their linen. V2 said there did not need to be an order in the chart for a resident to be on EBP. V2 also said EBP PPE is worn to protect themselves as well as the resident. V2 said hand hygiene should be done before care, between glove change, and after providing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 7 of 8 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 145711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Elmhurst 420 West Butterfield Road Elmhurst, IL 60126 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 care. Level of Harm - Minimal harm or potential for actual harm On June 7, 2023, at 1:11 PM, V4 went to R346's room and administered two of her oral medications without performing hand hygiene prior to administration. Facility's policy titled Medication Pass (March 28, 2023) documents: 7. PO (By Mouth) meds: a.) Follow hand hygiene procedure before and after each resident. Residents Affected - Some 6. On June 7, 2023, at 09:49 AM, incontinence care was being given to R31 by V17 (Restorative Aide) and V8 (CNA-Certified Nursing Assistant). V8 (CNA) did not change gloves after taking soiled incontinent brief off. V8 (CNA) proceeded to clean R31's perineum with the same gloves V8 (CNA) used to placed new incontinent pads on R31. On June 8, 2023, at 09:41 AM, interview with V2 (DON-Director of Nursing) stated during incontinence care, after removing soiled diaper, hand hygiene must be done, and staff should put new gloves on before cleaning the resident. After cleaning the resident, gloves must be removed, hand hygiene must be done, and new set of gloves should be applied. This is done to prevent urinary tract infection. Facility's Policy on Incontinent and Perineal Care dated December 3, 2015, and revised on July 28, 2022 stated the following: . Procedures .9. Put on new set of clean gloves to put on clean briefs/incontinent pads, to make resident comfortable, groom and change clothing. Facility's Policy on Hand Hygiene dated January 20, 2016, and revised on July, 28 2022 stated the following: .1. Hand Hygiene using alcohol-based hand rub is recommended during the following situations: a. Before and after resident contact.g. Before moving from work on soiled body site to a clean body site on the same resident. 7. On June 6, 2023, at 11:36 AM, R59 was in an EBP (Enhanced Barrier Precaution) room. EBP signage was posted on the door and isolation bin was outside room door. V10 (CNA/Certified Nurse Assistant) entered room with gloves on and assisted R59 with toileting. V10 assisted R59 to restroom, removed pants and soiled disposable brief, and assisted to sit on toilet riser. V10 wiped R59's perineal area and buttocks prior to assisting with applying new disposable brief. V10 removed gloves and did not perform hand hygiene prior to applying new gloves. On June 6, 2023, at 11:47 AM, V10 said R59 was on EBP for his wounds and they were told full PPE (Personal Protective Equipment) was only needed to be worn when in direct contact with his wound. V10 read the EBP signage on door and said, I see the sign but that's not what we were told. On June 8, 2023, at 8:55 AM, V7 (LPN/Licensed Practical Nurse) entered R59's room without any PPE on to answer his call light. R59 requested to be transferred back to his bed. R59 assisted him to a laying position and removed R59's compression stockings. On June 8, 2023, at 9:00 AM, V7 said R59 was on EBP for wound care and if she did not touch the wound, she does not need to wear any PPE. When V7 read the EBP sign on door, V7 said, Oh I didn't realize that. The facility's Enhanced Barrier Precaution revised on July 14, 2022, shows the EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's [Multi-Drug Resistant Organism] to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include a) Dressing, c) Transferring, d) Providing hygiene, e) Changing linens, f) Changing briefs or assisting with toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 8 of 8