Health inspection·September 19, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of March 30, 2023, which documents, in part, 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Reviewed the facility's policy titled Facility Responsibilities Resident Rights with an implemented date of 2/10/23, which documents in part, 1. Resident Rights. a. The facility will treat each resident with respect and dignity, and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Event ID: Facility ID: 145904 If continuation sheet Page 2 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility staff failed to complete the controlled substance shift to shift count form which is utilized to complete a shift-to-shift count for controlled substances. This failure has the potential to affect all 27 residents on the second floor and all 16 residents on the first floor. Findings include: On 09/17/2024 at 10:00AM with V13(RN/Registered Nurse) reviewed the second-floor medication cart's Controlled Substance Shift to Shift Count form for September 2024, this form is used by the facility for shift change accountability for controlled substances. The Nurse On and/or Nurse Off initial boxes were left blank for: September 08, 2024, PM Shift, - Nurse Off September 09, 2024, AM Shift-Nurse On September 11, 2024, PM Shift-Nurse Off On 09/17/2024 at 10:15AM with V14(RN/Registered Nurse) reviewed the first-floor medication cart's Controlled Substance Shift to Shift Count form for September 2024, this form is used by the facility for shift change accountability for controlled substances. The Nurse Off initial box was left blank for: September 04, 2024, 6PM - Nurse Off On 09/17/2024 at 10:06AM V13(RN/Registered Nurse) stated the nurses have been having trouble with the controlled substance shift to shift count sheets and getting confused. V13 stated two nurses are to count the controlled substances and sign on and off on the controlled substances shift to shift count sheet. V13 stated the nurses coming in to work and the nurses leaving for the day are to count the tablets in the medication cards of controlled substances to make sure the count of tablets are correct. V13 stated when both nurses agree that the count is correct, then both nurses initial the controlled substance shift to shift count sheet indicating the count for the controlled substances is correct. On 09/17/2024 at 10:17AM V14(Registered Nurse) stated the nurse coming in to work signs the controlled substance shift to shift count sheet with the nurse leaving the shift for the day. V14 stated the two nurses are to count the controlled substances together. V14 stated after both nurses verify that the count of the controlled substances is correct, then both nurses initial the controlled substance shift to shift count sheet for the correct date and time. On 09/18/2024 at 11:10AM V2(Director of Nursing) stated the nurses are responsible for completing the controlled substance shift to shift count sheets. V2 stated the incoming nurse is to count the controlled substances with the outgoing nurse to make sure the count of the controlled substances is correct. V2 stated the purpose of the controlled substance shift to shift count sheet is to make sure all narcotics are accounted for. V2 stated the nurses are to notify me, the DON (Director of Nursing) if the controlled substances shift to shift count sheet is not initialed and completed for each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 3 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 0755 shift. Level of Harm - Minimal harm or potential for actual harm On 09/18/2024 reviewed the facility's policy (dated June 2018, with a revision date of August 2024) titled Controlled Substance Administration & Accountability which documents, in part, 9. Inventory Verification: b. Two licensed nurses account for all controlled substances and access keys at the end of each shift. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 4 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to follow a resident's diet order for fluid restriction. This failure affected one resident (R37) out of 44 residents in the sample. Residents Affected - Few Findings include: R37's face sheet shows that R37's has diagnosis which include but not limited to acute on chronic diastolic (congestive) heart failure, chronic kidney disease and organ limited amyloidosis. R37's Brief Interview for Mental Status (BIMS) dated 08/19/24 shows that R37 has a BIMS score of 10 which indicates that R37 has some cognitive impairments. On 09/16/24 at 12:30 pm, R37's was observed in the second-floor dining room during the lunch meal. Surveyor observed R37 drink a 7.5 oz (ounce) can of ginger ale soda and then a 6.0 oz cup of water. Surveyor observed R37's diet card orders next to R37's lunch meal with the following dietary order documented in part: Diet Order: Regular texture no added salt, fluids thin. Notes Fluid restriction: provide the following only: 6 oz (ounces) water, coffee, juice, or soda- one of these options only . Alerts: 1500 mL (milliliter) fluid restrictions. On 09/16/24 at 12:42 pm, Surveyor questioned V7 (Dietician) regarding R37's lunch meal diet card fluid restrictions orders and V7 stated that R37 should have either water or ginger ale but not both due to R37's fluid restriction. V7 then stated, I (V7) did not give him (R37) that (referring to R37's water and ginger ale). The servers provide the drinks before the meals are served. They (referring to the servers) need to read the ticket (referring to R37's diet card). When V7 was asked regarding what could happen if a resident's diet card for fluid restrictions are not followed and V7 stated, R37 has CHF (Congestive Heart Failure) and if he (R37) drinks too much fluid, he (R37) could have issues with his (R37's) heart. I (V7) will in-service the servers. R37's diet card dated Mon (Monday) Sep (September) 16/24 shows that R37 has a diet order Diet Order: Regular texture no added salt, fluids thin. Notes Fluid restriction: provide the following only: 6 oz (ounces) water, coffee, juice, or soda- one of these options only . Alerts: 1500 mL (milliliter) fluid restrictions. R37's Physician Order Sheet (POS) dated 09/16/24 documents, in part: Diet: Fluid Restriction: 1500 mL daily 1080 mL, Nursing 420 mL every shift. R37's care plan presented on 09/17/24 documents, in part: Interventions: Provide fluid restriction as ordered per MD (Medical Director) (1500 mL (milliliter) day) (Dietary 1080 mL Nursing 420 mL. The facility's policy dated March 2022 and titled Therapeutic Diet Orders documented in part: Policy: the facility provides all residents with foods in appropriate form and/or the appropriate nutritive content as prescribed by physician, and/or assessed by the interdisciplinary team to support the residents treatment/plan of care, in accordance with his/her goals and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 5 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure foods were labeled, dated and maintained to prevent the spread of foodborne illness to all residents receiving oral nutrition. This failure has the potential to affect all residents. Findings include: On 9/15/2024 at 9:54am surveyor observed a 1.5 lb. container of uncovered beef patties (sliders) out of its original packaging and a roll of pepperoni wrapped in plastic with no received date or discard date. There was a bag of tilapia fish, not individually wrapped but open to air in its original container with no discard date. On 9/15/2024 at 9:57am V4 (Dietary Manager) stated no, they (beef patties-sliders) should not be in the freezer uncovered and all food items should be covered and have a received and discard date because you will not know when to discard the items. On 9/15/2024 at 10:02am surveyor observed two 5-gallon tubs of chocolate and pecan ice cream with the top not secured on the tubs in the dairy freezer. On 9/16/2024 at 10:17am surveyor observed (2) 1.5-gallon containers of Bread Battered Cod and Edamame Dumplings (1) with no lid (open to air) and not dated. On 9/16/2024 at 10:17am V4 (Dietary Manager) stated, yes, they (dumplings and bread battered cod) should be covered and dated to protect from cross contamination. Date Marking for Food Safety with a revised date of March 2022 documents, in part, the facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety. 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible to cover, label and date marking the food at the time the food is opened or prepared. 6. The Executive Chef, or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. Position Analysis for Dining Service Manager dated February 2020 documents, in part, Under the guidance of the Director of Dining Services, is responsible for overall service in the main dining room, health care, personal care, coffee shop, and special functions. These areas will be operated within established objectives, standards, policies, and procedures and 2. Assists in providing quality food. Undated job description titled Director of Dining Services, documents, in part, Oversee and participate in the preparation and service of food and beverage items in adherence to company food standards for preparation, presentation, sanitation and safety (meeting HACCP and OSHA guidelines) and portion control. Food Safety Policy with a revised date of 3/29/2023 documents, in part, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 6 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete professional standards for food service safety. 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. B. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. C. Refrigerated storage - Practices to maintain safe refrigerated storage include: iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and v. Keeping foods covered or in tight containers. Event ID: Facility ID: 145904 If continuation sheet Page 7 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to maintain temperature logs and provide thermometers for resident's personal refrigerators for two residents R1 and R29 to ensure the safety of the residents. This failure has the potential to affect all three residents (R1, R14 and R29) with personal refrigerators. Residents Affected - Few Findings include: On 9/16/2024 at 10:50am surveyor observed R1's refrigerator with no log or thermometer. On 9/18/2024 at 10:37pm surveyors observed R1's refrigerator with no log or thermometer. On 9/18/2024 at 10:38am V20 (Certified Nursing Assistant) stated that the kitchen staff is responsible for labeling and checking the food in resident's personal refrigerators every day. On 9/18/2024 at 9:18am V2 (Director of Nursing) stated that the family is responsible for cleaning, unthawing and discarding food from the resident's personal refrigerator. Policy titled Use and Storage of Food Brought in by Family or Visitors with a revised date of 3/26/2023 documents, in part, It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. On 09/16/2024 at 10:53am observed a black and gray refrigerator sitting in R29's room. Surveyor observed no thermometer in the inside of the refrigerator and no refrigerator temperature log to record a daily temperature affixed to R29's personal refrigerator. Surveyor observed 6 cartons of a nutritional drink, 2 containers of Jello, applesauce, and 27 cans of soda in R29's personal refrigerator. On 09/17/2024 at 10:12 am V13(RN/Registered Nurse) stated I am not sure who is responsible for maintaining and taking the temperatures in the refrigerators for resident's who have personal refrigerators. On 09/17/2024 at 2:09pm V8 (Environment Service Director) stated I do not know who is monitoring the temperature daily in resident's personal refrigerators. On 09/18/2024 at 11:10 am V2(DON/Director of Nursing) stated the resident's personal refrigerators are maintained by the resident's family. V2 stated the facility does not have a policy regarding the care and maintenance of resident's personal refrigerators. V2 stated if the temperature in a resident's personal refrigerator is not within an acceptable range, the food in the resident's personal refrigerator will spoil and cause the resident to experience gastrointestinal upset or discomfort. R29's Brief Interview for Mental Status (BIMS) dated 07/25/2024 Section C C0500 documents that R29 has a BIMS score of 13 which indicates that R29 is cognitively intact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 8 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the garbage dumpster lids were closed. This failure has the potential to affect all residents residing in the facility. Residents Affected - Many Findings include: On 9/16/2024 at 10:11am surveyor observed a blue garbage dumpster with both lids open. Surveyor observed V4 (Dining Service Manager) close both lids on the blue garbage dumpster. On 9/16/2024 at 10:11am V4 (Dining Service Manager) stated, no, the lids should not be open, but the CNAs use the dumpsters too. On 9/18/2024 at 12:30pm V8 (Environment Service Director) stated that the dumpster lids should be closed on the dumpsters. Policy titled Disposal of Garbage and Refuse with an implemented date of 2/10/2023, documents, in part, Garbage and refuse containers shall be covered when not in use and 7. Containers and dumpsters shall be kept covered when not being loaded. Undated job description titled EVS Director documents, in part, Plans, organizes and directs all functions of Environmental Services to provide for a safe, clean, functional and comfortable environment, adhering to regulatory requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 9 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 ensure a resident (R21) with a chronic wound was placed on Enhanced Barrier Precautions (EBP). This failure has the potential to affect all 27 residents on the second floor. Residents Affected - Some Findings include: On 09/16/24 at 9:50 am, V1 (Administrator) presented a facility census of 27 residents on the second floor. R21's face sheet shows that R21's has diagnosis which include but not limited to unspecified malignant neoplasm of skin and other symptoms and signs involving the musculoskeletal system. R21's Brief Interview for Mental Status (BIMS) dated 06/24/24 shows that R21 has a BIMS score of 6 which indicates that R21 has some cognitive impairments. On 09/17/24 at 9:52 am, Surveyor observed R21 in bed resting with no EBP sign or Personal Protective Equipment (PPE) bin inside or near R21's room. On 09/17/24 at 9:54 am, V9 (Registered Nurse, RN, Wound Care Nurse) and V10 (Certified Nursing Assistant, CNA) were observed performing high-contact resident care activities (wound care to R21's left ischium stage 4 pressure ulcer chronic wound and ADL (Activities of Daily Living) care (providing hygiene and changing R21's incontinence pad that was saturated with stool) without wearing PPE (gown) in R21's room. On 09/17/24 at 10:00 am, V9 (Registered Nurse, RN, Wound Care Nurse) was asked regarding residents who require EBP and V9 stated that residents with indwelling catheters, ostomy, and wounds require EBP. When V9 was asked regarding R21 requiring EBP V9 stated, I (V9) don't know why he (R21) is not on EBP. You (referring to the surveyor) will have to ask V3 (Infection Preventionist). When V9 was asked regarding the importance of residents who require EBP due to having a chronic wound being placed on EBP and V9 stated, To avoid an infection. When V9 was asked regarding the proper PPE for residents who require EBP for high contact care such as wound care dressing changes and ADL care and V9 stated, A gown and gloves. 09/17/24 at 10:03 am, V10 was asked regarding residents who require EBP and V10 stated that V10 is made aware of residents who require EBP by checking the resident's room for a EBP sign placed on the resident's door and a PPE bin in the residents' room. V10 explained that if a resident does not have a EBP sign on the resident's door then V10 is not aware of the resident requiring EBP. On 09/17/24 at 10:13 am, V11 (Certified Nursing Assistant, CNA, Agency) was observed performing ADL care (dressing) with R21 without wearing proper EBP PPE (gown). On 09/17/24 at 10:14 am, V3 (Infection Preventionist, IP, Registered Nurse, RN) was asked regarding residents who require EBP and V3 stated, R21 does not require EBP. His (R21) wound is not chronic and does not have a history of MDRO (Multidrug-Resistant Organism). Only wounds that are chronic with MDRO require EBP. If his (R21) was a heavily draining wound without a bandage, then we would place him (R21) on EBP. Surveyor questioned V3 regarding wounds that are considered chronic wounds and V3 stated, I (V3) will have to look at his (R21) co-morbidities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 10 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 09/17/24 at 10:20 am, V2 (Director of Nursing, DON) was asked regarding a resident with EBP and V2 stated that residents with lines, drains, catheters, PICC (Peripherally Inserted Central Catheter) lines, history of MDRO's and chronic wounds require EBP. When V2 was asked regarding the purpose of residents being placed on EBP and V2 stated, To protect the staff and residents from MDRO transmission. When V2 was asked regarding how staff are made aware of residents who require EBP and V2 stated that a EBP sign is placed on the resident's door and through the nurses 24-hour report. When V2 was asked regarding what could happen if a resident who requires EBP is not placed on EBP and V2 stated, There is a risk of the resident getting an infection. The facility undated document titled Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high contact resident care activities Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs for assisting with toileting, device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound care: Any skin opening requiring a dressing. The facility's document dated October 20, 2023, and titled Enhanced Barrier Precautions documents, in part: Policy: it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms (MDRO's). Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisitions (e.g. (example), residents with wounds or indwelling medical devices). Policy explanation and compliance guidelines: 2. Initiation of enhanced barrier precaution b. Enhanced barrier precautions will be initiated for residents with any of the following i. Significant wounds e.g., chronic wounds or skin openings such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, chronic venous stasis ulcers, stomas) and/or and dwelling medical devices (e.g., central lines, midlines, hemodialysis catheters, urinary catheters, plural drain, feeding tubes etc.) Even if the resident is not known to be infected or colonized with MDRO. Not intended for minor skin tears or cuts. 4. High contact resident care activities include: a. Dressing. b. Bathing. c. Transferring. d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: centralized, urinary catheters, feeding tubes. h. Wound care: any skin openings requiring a dressing. 7. Enhanced barrier precautions should be used for the duration of the affected residents stay in the facility or until the wound heals or indwelling medical device is removed. R21's Physician Order Sheet (POS) shows that R21 has orders for Left Ischium: Cleanse with skin integrity, pat, dry, lightly pack with collagen, apply moisture barrier to the peri wound and cover with ABD (abdominal) pad. R21's POS dated 09/17/24 documents in part: Precautions: Enhanced Barrier Precautions. R21's care plan dated 09/17/24 documents, in part: Focus: Enhanced Barrier Precautions initiated due to resident having chronic wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 11 of 11