Health inspection·July 10, 2025

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 ensure three residents (R1, R2, and R5) were properly placed on enhanced barrier precautions, staff were adequately informed of isolation procedures and failed to follow their infection precaution guideline procedure. This failure has the potential to affect all 14 residents currently residing on the South-2 Unit.Findings include:Per facility census dated 7/9/2025 shows 14 residents residing in the South-2 Unit.R1 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: acute myelitis in demyelinating disease of central nervous system, dementia, altered mental status, multiple contractures, need for assistance with personal care, urinary tract infection, ESBL (Extended-Spectrum Beta-Lactamase), quadriplegia, COPD (Chronic obstructive pulmonary disease), and anxiety. It is to be noted that R1 has multiple wounds and a urinary catheter. R2 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: ESRD (End-Stage Renal Disease) dependent on dialysis, type II DM (Diabetes Mellitus), lack of coordination, pneumonia, sepsis, muscle wasting, difficulty in walking, abnormal posture, and prostate cancer. It is to be noted that R2 has a dialysis port, a central venous catheter, and multiple wounds.R4 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R4 has multiple diagnoses including but not limited to the following: CKD (Chronic Kidney Disease), CHF (Congestive Heart Failure), type II DM, and repeated falls. It is to be noted that R4 has a VRE (Vancomycin-Resistant Enterococci) infection in his wound.R5 is a [AGE] year-old male who originally admitted to the facility on and continues to reside in the facility. R5 has multiple diagnoses including but not limited to the following: quadriplegia, depression, MRSA (Methicillin-Resistant Staphylococcus aureus), UTI (Urinary Tract Infection), anxiety, seizures, cachexia, obstructive uropathy, and psychotic disorder.It is to be noted that R5 has a urinary catheter and an active pressure ulcer.Order Listing Report dated 7/8/2025 shows R5 on Enhanced Barrier Precautions due to suprapubic catheter and wounds. R4 is on Contact Isolation for VRE of the wound. It is to be noted that R1 or R2 are not on the Enhanced Barrier Precautions list.On 7/8/2025 at 11:20AM, observed R2 and R5's room to have no enhanced barrier sign on door or isolation bin outside of door. At 11:30AM, observed V7 (Certified Nursing Assistant) changing linens to R1's bed. V7 was wearing gloves, however no gown or mask was worn. At 11:45, V6 (Certified Nursing Assistant) was asked about enhanced barrier precautions and contact isolation. V6 was noted to be confused and unable to accurately describe the differences between isolations and the expectations of CNA's regarding infection control when dealing with residents on various types of isolations.At 11:55AM, V7 (Certified Nursing Assistant) was also asked about enhanced barrier precautions and contact isolation. V7 was also unable to accurately describe the differences between isolations and the expectations of CNA's regarding infection control Residents Affected - Some Page 1 of 2 145877 145877 07/10/2025 Aperion Care Dolton 14325 South Blackstone Dolton, IL 60419

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when dealing with residents on various types of isolations.At 1:10PM, V8 (Certified Nursing Assistant) was observed entering R4's room (who was on contact isolation) not wearing any PPE's.On 7/9/2025 at 11:16AM, V12 (Certified Nursing Assistant) was observed in R4's room assisting resident with transferring from bed to wheelchair. R4 was noted to be wearing gloves, however no mask or gown was worn. V12 assisted R4 with transferring, repositioning, and fixed wheelchair. V12 exited room wearing gloves, grabbed bag of soiled linen from hallway, and put soiled linen from R4's bed in bag. V12 then began making R4's bed with clean linen without changing gloves or conducting hand hygiene. V12 then carried soiled linen bag out to hallway and grabbed a clean sheet from clean linen cart, still wearing same gloves. V12 then grabbed R4 a soft drink off of dresser which R4 began to drink.V12 said she was unaware that R4 was on contact isolation, but she does see the contact isolation sign on his door and isolation bin outside of his room. V12 said I should have worn gloves, mask, and a gown when caring for R4. It is to be noted that V12 was also unable to adequately explain expectations of CNA's when a resident is on enhanced barrier precautions and was unable to provide this surveyor with a time she was in-serviced on isolation.At 1:30PM, V2 (Director of Nursing) said residents who have wounds or a medical device that cause an opening to the body should be on enhanced barrier precautions. This is to help prevent the spread of infection. My expectation would be that any staff providing direct patient care would be expected to wash their hands before and after and wear a gown, gloves, and a mask when providing care. Asked V2 when the last time the staff was in-serviced on isolation. V2 provided this surveyor with an in-service for enhanced barrier precautions dated 4/8/2025. V2 said staff is also trained on many things upon hire.Facility Contact Precautions sign shows providers must put on gloves and gown before entering room and discard upon exiting room. Facility Enhanced Barrier Precautions sign shows providers and staff must put on gloves and gown for the following high contact resident care activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and wound care.Facility policy titled Infection Prevention Guidelines with last revision date of 5/15/2023 states in part but not limited to the following: It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of isolation precautions. 145877 Page 2 of 2