Health inspection·March 15, 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 ensure that the urine collection bag was covered and that complete privacy is provided during wound care for three of four residents (R25, R217, R220) reviewed for resident's rights in a sample of 14. Findings include: 1. R25's Profile Face Sheet indicated R25 was admitted in the facility on 02/26/2024 with diagnoses of not limited to unspecified dementia and cardiomyopathy. R25's Physician's Orders for 3/14/2024 indicated treatment order for right heel DTI (deep tissue injury). On 03/13/2024 at 10:40AM during wound care observation, V11 (Wound Nurse) was observed proceeding with R25's wound care treatment without closing the door and pulling the privacy curtain completely around R25's patient care area. R25's room was observed as a 2-bed room. On 03/13/2024 at 10:52AM, V11 stated even though the curtain was not completely pulled to cover R25's patient care area, it was enough to provide privacy during R25's wound care treatment since R25 was not visible from the hallway. V11 also stated since R25 was not visible from the hallway, closing the door is not necessary to provide privacy. On 03/14/2024 at 11:30AM, V2 (Director of Nursing), V2 stated, Before performing all procedures and treatments, pulling the privacy curtain around the patient care area and closing the door has to be done to provide privacy for the resident. 2. R217's Profile Face Sheet indicated R217 was admitted in the facility on 03/04/2024 with diagnoses of not limited to crossing vessel and stricture of ureter without hydronephrosis. R217's Physician's Orders for 3/14/2024 indicated foley orders with order date of 3/4/2024. On 03/12/2024 at 10:22AM, R217 was observed lying in bed with urine collection bag placed on the side of the bed facing the hallway, uncovered. R217's door was also observed wide open. At 11:00AM, R217 was again observed lying in bed with urine collection bag placed on the side of the bed facing the hallway, uncovered. R217's door was again observed wide open. On 03/12/2024 at 11:00AM, V5, Registered Nurse, stated usually they do not provide a privacy bag if Page 1 of 8 145827 145827 03/15/2024 British Home, The 8700 West 31st Street Brookfield, IL 60513

F 0550 the resident is in the room; that is why R217's urine collection bag was not in the privacy bag. Level of Harm - Minimal harm or potential for actual harm 3. R220's Profile Face Sheet indicated R220 was admitted in the facility on 03/07/2024 with diagnoses of not limited to benign prostatic hyperplasia without lower urinary tract symptoms and obstructive and reflux uropathy. Residents Affected - Few R220's Physician's Orders for 3/14/2024 indicated indwelling catheter orders with order date of 3/7/2024. On 03/12/2024 at 12:31PM, R220 was observed lying in bed with urine collection bag placed on the side of the bed facing the hallway, uncovered. R220's door was also observed wide open. At 12:40PM, R220 was again observed lying in bed with urine collection bag placed on the side of the bed facing the hallway, uncovered. R220's door was again observed wide open. On 03/12/2024 at 12:40PM, V5 stated usually they do not provide a privacy bag if the resident is in the room; that is why R220's urine collection bag is not in the privacy bag. On 03/14/2024 at 11:30AM, V2 (Director of Nursing), V2 stated, If the urine collection bag is visible from the hallway, it should have a privacy bag for dignity. Review of facility's policy entitled Quality of Life-Dignity reviewed on 2/20/2024 indicated the following: Purpose: (Facility) supports that each resident shall be treated with respect and dignity to enhance the quality of life. The following policy highlights procedures. Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity respect and individuality. Procedures: 1. Residents shall be treated with dignity and respect at all times. 6. Residents' private space and property shall be respected at all times. c. Staff will respect resident's privacy by closing their door/curtain when providing care. 10. Team Members shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 145827 Page 2 of 8 145827 03/15/2024 British Home, The 8700 West 31st Street Brookfield, IL 60513

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to transmit admission and discharge assessments within 14 days of completion for six of six residents (R6, R39, R40, R45, R52, R54) reviewed for resident assessments in a sample of 14. Residents Affected - Some Findings include: 1. R39's Profile Face Sheet indicated R39 was admitted in the facility on 10/17/2023 and discharged on 11/4/2023. On 03/14/2024 at 1:48PM, during review with V13 (MDS Coordinator), R39's admission date was noted at 10/17/2023, and admission assessment was scheduled on 10/23/2023, which was submitted on 11/21/2023. R39's discharge date and assessment were noted on 11/4/2023. On 03/14/2024 at 1:48PM, V13 stated all assessments should be submitted within 14 days of completion, so R39's admission assessment should have been submitted by 11/5/2023, and R39's discharge assessment should have been submitted by 11/17/2023. On 03/15/2024 at 9:45AM, V13 stated R39's discharge assessment was not submitted until 03/14/2024, when V13 tried to obtain a transmission documentation for R39. 2. R54's Profile Face Sheet indicated R54 was admitted in the facility on 10/25/2023 and discharged on 11/10/2023. On 03/14/2024 at 1:48PM, R54's admission date was noted at 10/25/2023, and admission assessment was scheduled on 10/30/2023, which was submitted on 11/21/2023. R54's discharge date and assessment were noted on 11/10/2023. On 03/14/2024 at 1:48PM, V13 stated all assessments should be submitted within 14 days of completion, so R54's admission assessment should have been submitted by 11/12/2023, and R54's discharge assessment should have been submitted by 11/23/2023. On 03/15/2024 at 9:45AM, V13 stated R54's discharge assessment was not submitted until 03/14/2024, when V13 tried to obtain a transmission documentation for R54. 3. R52's Profile Face Sheet indicated R52 was admitted in the facility on 10/27/2023 and discharged on 11/10/2023. On 03/14/2024 at 1:48PM, R52's admission date was noted at 10/27/2023, and admission assessment was scheduled on 10/31/2023, which was submitted on 11/21/2023. R52's discharge date and assessment were noted on 11/10/2023. On 03/14/2024 at 1:48PM, V13 stated all assessments should be submitted within 14 days of completion, so R52's admission assessment should have been submitted by 11/14/2023, and R52's discharge assessment should have been submitted by 11/24/2023. On 03/15/2024 at 9:45AM, V13 stated R52's discharge assessment was not submitted until 03/14/2024, 145827 Page 3 of 8 145827 03/15/2024 British Home, The 8700 West 31st Street Brookfield, IL 60513

F 0640 when V13 tried to obtain a transmission documentation for R52. Level of Harm - Minimal harm or potential for actual harm 4. R45's Profile Face Sheet indicated R45 was admitted in the facility on 10/06/2023 and discharged on 11/3/2023. Residents Affected - Some On 03/14/2024 at 1:48PM, R45's admission date was noted at 10/06/2023, and admission assessment was scheduled on 10/13/2023, which was submitted on 11/6/2023. R45's discharge date and assessment were noted on 11/3/2023. On 03/14/2024 at 1:48PM, V13 stated all assessments should be submitted within 14 days of completion, so R45's admission assessment should have been submitted by 10/26/2023, and R45's discharge assessment should have been submitted by 11/16/2023. On 03/15/2024 at 9:45AM, V13 stated R45's discharge assessment was not submitted until 03/14/2024, when V13 tried to obtain a transmission documentation for R45. 5. R6's Profile Face Sheet indicated R6 was admitted in the facility on 10/16/2023 and discharged on 11/9/2023. On 03/14/2024 at 1:48PM, R6's admission date was noted at 10/16/2023, and admission assessment was scheduled on 10/23/2023, which was submitted on 11/21/2023. R6's discharge date and assessment were noted on 11/9/2023. On 03/14/2024 at 1:48PM, V13 stated all assessments should be submitted within 14 days of completion, so R6's admission assessment should have been submitted by 11/5/2023, and R6's discharge assessment should have been submitted by 11/22/2023. On 03/15/2024 at 9:45AM, V13 stated R6's discharge assessment was not submitted until 03/14/2024, when V13 tried to obtain a transmission documentation for R6. 6. R40's Profile Face Sheet indicated R40 was admitted in the facility on 10/2/2023 and discharged on 10/19/2023. On 03/14/2024 at 1:48PM, R40's admission date was noted at 10/2/2023, and admission assessment was scheduled on 10/8/2023, which was submitted on 11/21/2023. R40's discharge date and assessment were noted on 10/19/2023. On 03/14/2024 at 1:48PM, V13 stated all assessments should be submitted within 14 days of completion, so R40's admission assessment should have been submitted by 10/21/2023, and R40's discharge assessment should have been submitted by 11/1/2023. On 03/15/2024 at 9:45AM, V13 stated R40's discharge assessment was not submitted until 03/14/2024, when V13 tried to obtain a transmission documentation for R40. 145827 Page 4 of 8 145827 03/15/2024 British Home, The 8700 West 31st Street Brookfield, IL 60513

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 implement infection control practices for storage of respiratory care supplies for one of four residents (R59) reviewed for respiratory care in a sample of 14. Residents Affected - Few Findings include: R59's Profile Face Sheet indicated R59 was admitted in the facility on 02/15/2024, with diagnoses of not limited to other pneumonia and malignant neoplasm of unspecified part of unspecified bronchus or lung. R59's Physician's Orders for 3/14/2024 indicated nebulization treatment order, with the order date of 02/15/2024. On 03/12/2024 at 10:50AM, R59's bare nebulization mask was observed placed on top of R59's nightstand. At 12:40PM, R59's bare nebulization mask was again observed placed on top of R59's nightstand. On 03/12/2024 at 10:59AM, V5, Registered Nurse, stated R59's nebulization mask should be placed in a bag. On 03/14/2024 at 11:30AM, V3 (Nurse Manager/Infection Preventionist), stated, If the nebulization mask is not in use, it should be stored in a bag for protection. Review of facility's policy entitled Infection Prevention and Control Program copyrighted 2023 indicated the following: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe and sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 10. Equipment Protocol: c. Reusable items potentially contaminated with infectious materials shall be placed in an impervious clear plastic bag. 145827 Page 5 of 8 145827 03/15/2024 British Home, The 8700 West 31st Street Brookfield, IL 60513

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation, interview, and record review, the facility failed to label a multi-dose medication with an open and a used by date. The facility also failed to lock the medication refrigerator in the medication room for the first floor, for one of one medication rooms reviewed for medication storage. Findings include: On 3/13/24 at 9:30am, during medication observation with V2 (Director of Nursing), in the first-floor medication storage room, the following were noted: 1. An opened medication fridge with the lock not secured. 2. An opened Tuberculin, Purified Protein Derivative, Diluted Aplisol 5TU/0.1ml vial with a dispense date of 3/6/24, with no open or discard date. On 3/13/24 at 9:30am, V2 stated the vial should be labeled with an open and discard date, and the medication fridge should be always be locked. Facility policy titled, Administering Medications. Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 12. The expiration/beyond use date on the medication liable is checked prior to administering. When opening a multi-does container, the date opened is recorded on the container; or the medication delivery date is used. 145827 Page 6 of 8 145827 03/15/2024 British Home, The 8700 West 31st Street Brookfield, IL 60513

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 maintain infection control practices during wound care for one of one resident (R25) reviewed for wound care in a sample of 14. Residents Affected - Few Findings include: R25's Profile Face Sheet indicated R25 was admitted in the facility on 02/26/2024, with diagnoses of not limited to unspecified dementia and cardiomyopathy. R25's Physician's Orders for 3/14/2024 indicated treatment order for right heel DTI (deep tissue injury). On 03/13/2024 at 10:40AM , V11 (Wound Nurse) was observed putting all the wound dressing supplies on the bedside table without disinfecting it and/or putting a liner on top of it, after V8 (Certified Nursing Assistant) removed three empty cups on top of the bedside table. V11 was also observed not performing hand hygiene in between changing gloves for the duration of the wound care treatment. V11 was also observed not changing gloves and performing hand hygiene after removing the soiled dressing and before cleaning the wound site. On 03/13/2024 at 10:52AM, V11 stated she usually has a towel with her that she uses as barrier from the surface and dressing supplies to keep it clean, but V11 did not have it at this moment because she was not prepared. V11 also stated she should have performed hand hygiene in between glove changes but she did not. On 03/14/2024 at 11:30AM, V2 (Director of Nursing), V2 stated V11 should have put a barrier or liner on top of the bedside table before she placed the dressing supplies on top of the bedside table. V2 also stated V11 should have removed her gloves after removing the soiled dressing, performed hand hygiene, put on another set of gloves, and proceeded with cleaning the wound site. V2 also said V11 should have performed hand hygiene in between glove changes. Review of facility's policy entitled Wound Care revised October 2010 indicated the following: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the procedure: 1. Place all items to be used during the procedure on the clean field. Arrand the supplies so they can be easily reached. Review of facility's policy entitled Hand Hygiene copyrighted 2023 indicated the following: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 145827 Page 7 of 8 145827 03/15/2024 British Home, The 8700 West 31st Street Brookfield, IL 60513

F 0880 6. Additional considerations: Level of Harm - Minimal harm or potential for actual harm a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, immediately after removing gloves. Residents Affected - Few Hand Hygiene Table indicated to use either soap and water or alcohol based hand rub (ABHR is preferred) on conditions including after handling contaminated objects, and before and after handling clean or soiled dressings, linens, etc. 145827 Page 8 of 8