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 staff donned all applicable
Personal Protective Equipment (PPE) for a resident with Enhanced Barrier Precautions (EBP) and sign was
posted indicating EBP for 2 of 3 residents (R2, R1) reviewed for infection control in the sample of 3.
Residents Affected - Few
The findings include:
On 4/29/25 this surveyor was provided a list of residents on Enhance Barrier Precaution (EBP) that
included R2 and R1 due to chronic wounds. V2 (Director of Nursing (DON) said all residents that were on
EBP have an orange dot by their names outside their rooms and on EBP sign inside the room.
1. On 4/29/25, at 10:10 AM, An orange dot was noted by R2's name outside of his room. V3 (Certified
Nursing Assistant-CNA) was in R2's room providing morning care to R2. A sign was noted on R2's head of
the bed, Enhance Barrier Precaution. (EBP).
R2 was being gotten up from bed. V3 (CNA) applied new incontinent brief, pulled his pants up then V3
transferred R2 from his bed to his wheelchair. V3 (CNA) proceeded to remove R2's soiled linens from the
bed and applied new linens. V3 completed all these tasks with gloves on but not wearing a gown.
At 10:30 AM, V3 (CNA) said R2 was on EBP precautions due to his wounds. V3 said she should have worn
gown and gloves to prevent cross contamination.
R2's careplan dated 3/17/25 documents, Resident is on enhanced barrier precautions. Patient on EBP per
applicable infection prevention and control standards and regulation. Prevent the spread of infection.
Maintain precautions as indicated.
2. On 4/29/25 at 9AM, R1's name outside of his door had no orange dot. There was no EBP sign inside his
room. R1 showed this surveyor a dressing to his right knee and said this was an unhealing wound from
surgery last March 2025. R1 said he just completed his oral antibiotics for possible wound infection.
On 4/29/25 at 10:50 AM, V2 (Director of Nursing) said R1 has a surgical wound that requires daily wound
dressing. R1 is on EBP. R1 should have a sign to show precautions to be observed due to EBP. R1 used to
be in a different room. R1's EBP sign might have been removed during the move or when housekeeping
was cleaning his room.
V2 also said when providing care to EBP residents, staff should wear PPE of gloves and gown to
(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:
145936
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
145936
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aliya of Highwood
50 Pleasant Avenue
Highwood, IL 60040
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
prevent the spread of infection.
Level of Harm - Minimal harm
or potential for actual harm
On 4/29/25 at 1:30 PM, V6 (Infection Control Nurse) said an EBP sign should be placed in the room of an
EBP resident to indicate the precautions the staff has to observe and what PPE to wear.
Residents Affected - Few
R1's careplan with initiated date of 4/29/25 (today) as confirmed by V2 (DON) show, Resident is on
enhanced barrier precautions . per applicable infection prevention and control standards and regulation.
Prevent the spread of infection. Maintain precautions as indicated
The facility policy entitled Enhanced Barrier Precaution with revision date of 3/20/24 documents, EBP
expands the use of PPE and refer to the use of gown and gloves during high-contact resident activities that
provide opportunities for transfer of MDRO's to staff hands and clothing. MDRO's may be indirectly
transferred from resident to resident during these high contact care activities. Nursing home residents with
wounds and indwelling devices are especially high risk of both acquisition and colonization with MDRO's.
The use of gown and gloves for high contact resident activities is indicated . High contact resident care
activities requiring gown and glove use that trigger EBP use include: Wound care, dressing,
bathing/showering, transferring, changing linens, changing brief/assisting in toileting, devices use-central
line, urinary catheter, feeding tubes .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145936
If continuation sheet
Page 2 of 2
