Health inspection·April 29, 2025

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 Page 1 of 2 145936 145936 04/29/2025 Aliya of Highwood 50 Pleasant Avenue Highwood, IL 60040

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 . 145936 Page 2 of 2