Health inspection·November 8, 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 procedures to ensure (a) signage outside of the resident's room indicating Enhanced Barrier Precaution (EBP) was posted; (b) PPE (Personal Protective Equipment) was made available and accessible outside of the resident's room; (c) Position a trash can inside R2's room and near the exit for discarding PPE after removal and (d) proper PPE were worn by staff when providing high contact resident care activities to 1 (R2) resident. These failures have the potential for cross contamination to 48 residents residing on the 4th floor as of census 11/6/24 reviewed for improper nursing care. Residents Affected - Some The findings include: R2's admission record showed admission date on 10/9/2024 with diagnoses not limited to Metabolic encephalopathy, Sudden visual loss, Dysphagia, Colostomy status, Hypotension, Unspecified kidney failure, Unspecified abdominal pain, Gastrostomy status. On 11/6/24 at 10:48 AM Observed R2 sitting up on wheelchair, alert and verbally responsive with confusion. V12 donned gloves and opened R2's G-tube dressing. V12 did not wear gown while providing care or use of feeding tube. No EBP signage by R2's door or wall outside of the room. Did not observe PPE supplies outside of R2's room, no trash can near the exit of the room for discarding PPE after removal. At 12:59 PM Observed V12 donned gloves and brought Jevity 1.5 8 fluid oz (ounce) and water to R2's room. V12 checked g-tube patency by auscultation. V12 checked gastric residual and aspirated a total of 360ml yellowish gastric contents. Observed V12 administered medications. V12 stated if gastric residual is more than 100ml to hold G-tube feeding. R2's G-tube feeding was not given. V12 administered 360ml gastric residual via G-tube by gravity and flushed G-tube with 135cc water. V12 was not wearing proper PPE (gown) during the whole process. At 1:12 PM V15 (Certified Nursing Assistant / CNA) stated she is working or assigned to R2 who is incontinent of bladder, requires extensive assistance with activities of daily living (ADL). V15 stated she provided incontinence care, hygiene, dressing to R2 today and donned gloves but did not wear gown because R2 is not on isolation. On 11/7/24 at 9:37 AM V24 (IP / Infection Preventionist nurse) stated V24 has been working in the facility for 4 years and as IP nurse for 2 years. V24 said Enhance Barrier Precautions / EBP is applicable for those residents with medical indwelling devices such as G-tube. It's important to make sure infection control / prevention policy and procedures are being followed by staff. V24 said for EBP there should be an order, care plan, signage on the door, and PPE supplies accessible to staff (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145864 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 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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)