Health inspection·January 17, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to knock on resident's doors before entering for three of 36 (R5, R62, R207) reviewed for dignity in a sample of 36. Residents Affected - Few Findings include: 1. On 01/14/2025 at 10:46AM during unit rounds with V32 (Wound Care Coordinator), V32 entered R5's room without knocking. On 01/14/2025 at 10:50AM during interview with V32, V32 stated that she did not knock on the door before entering R5's room. V32 stated that she should have knocked before entering R5's room. Review of R5's care plan for abuse, neglect, exploitation, trauma revised on 11/06/2024 indicated a goal to treat R5 with respect, sensitivity, dignity, and feel safe while living in the facility. Review of R5's care plan also indicated admission date of 06/13/2023 and diagnoses of not limited to obstructive sleep apnea and age-related physical debility. 2. On 01/14/2025 at 10:47AM during unit rounds with V32 (Wound Care Coordinator), V32 entered R62's room without knocking. On 01/14/2025 at 10:50AM during interview with V32, V32 stated that she did not knock on the door before entering R62's room. V32 stated that she should have knocked before entering R62's room. Review of R62's care plan for abuse, neglect, exploitation, trauma initiated on 11/05/2024 indicated a goal to treat R62 with respect, sensitivity, dignity, and feel safe while living in the facility. Review of R62's Order Summary Report dated 01/15/2025 indicated admission date of 04/29/2020 and diagnoses of not limited to Anxiety Disorder, Schizoaffective Disorder, Bipolar type, and Major Depressive Disorder. 3. On 01/14/2025 at 10:48AM during unit rounds with V32 (Wound Care Coordinator), V32 entered R207's room without knocking. On 01/14/2025 at 10:50AM during interview with V32, V32 stated that she did not knock on the door before entering R207's room. V32 stated that she should have knocked before entering R207's room. Review of R207's care plan for abuse, neglect, exploitation, trauma revised on 01/03/2025 indicated Page 1 of 25 145969 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0550 a goal to treat R207 with respect, sensitivity, dignity, and feel safe while living in the facility. Level of Harm - Minimal harm or potential for actual harm Review of R207's Order Summary Report dated 01/15/2025 indicated admission date of 12/20/2024 and diagnoses of not limited to Kyphosis, Adult Failure to Thrive, and other Cerebral Infarction due to occlusion or stenosis of small artery. Residents Affected - Few Review of facility's policy entitled Dignity reviewed/revised on 4/23/2018 indicated the following: Guidelines: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider resident's lifestyle and personal choices identified through the assessment processes to obtain a picture of his or her individual needs and preferences. Maintaining a resident's dignity should include but is not limited to the following: - Protecting and valuing resident's private space (for example, knocking on doors and requesting permission before entering, closing doors as requested by the resident); 145969 Page 2 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 1/14/25 at 7:02AM, Observed R191 lying in bed with right arm flexion contracture. His call light is placed on his bedside dresser, not within reach. Called V9 Nursing supervisor and showed observation made. V9 said that resident's call light should be within reach. She took the call light and placed within R191's reach. Residents Affected - Some R191 is admitted on [DATE] with diagnosis listed in part but not limited to non-traumatic intracerebral hemorrhage in hemisphere subcortical, Hemiplegia and hemiparesis following non traumatic intracerebral hemorrhage affecting right dominant side, Seizures, Cerebral edema, Aphasia, Dysphagia, Gastrostomy. 5. On 1/14/25 at 7:12AM, Rounds made to R261 with V9 Nursing Supervisor. Observed 261 lying in bed with language barrier. He speaks Spanish and making hand gesture to elevate his head. Observed call light is on the floor. V9 said that resident's call light should be within reach. She picked up the call light and placed within R261's reach. R261 is admitted on [DATE] with diagnosis listed in part but not limited to hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side, Respiratory failure, Type 2 Diabetes Mellitus. Based on observation, interview, and record review the facility failed to ensure resident call light is within reach. This deficiency affects 5 (R11, R102, R148, R191, R261) of 5 residents in the sample for 36 reviewed for accommodation of needs. Findings include: 1. On 1/14/25 at 7:35 AM, R148 observed in bed alert and verbal with feet touching foot board. R148 said that she could not reach her call light. Call light observed behind bedside dresser on floor. On 1/14/25 at 8:06 AM, V5 (Registered Nurse) said that call light should be kept within reach in case the resident needs assistance. V5 said the call light should not be behind dresser on the floor. R148 is admitted on [DATE] with diagnosis in part but not limited to type 2 diabetes mellitus without complications, generalized anxiety disorder, history of falling, other lack of coordination. A focused care plan for alteration in comfort indicated intervention including call light within reach dated 10/03/24. 2. On 1/15/25 at 10:42 AM, R11 observed in wheelchair alert and verbal, clean and dry no odors in the room. Call light observed behind dresser on the floor. R11 said she could not reach call light, she said usually staff hangs it on side rail. On 1/15/25 at 10:55 AM, V6 (Licensed Practical Nurse) said that staff must have forgot to put call light within reach when they got her up into the wheelchair. V6 said that call light should not be behind dresser, it should be within resident reach in case they need assistance. R11 is admitted on [DATE] with diagnosis in part but not limited to type 2 diabetes mellitus with stable proliferative diabetic retinopathy, difficulty in walking, history of falling, primary 145969 Page 3 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some osteoarthritis. A focused care plan for at risk for falls and injury related to osteoarthritis, requires assistance with activities of daily living indicated interventions including ensure the resident call light is within reach and encourage the resident to use it for assistance as needed dated 6/1/19. 3. On 1/15/25 at 10:50AM, R102 observed in bed alert and verbal, observed call light on floor under wheelchair. On 1/15/25/ at 10:55 AM, V6 (Licensed Practical Nurse) said that call light should not be on floor under wheelchair, it should be within resident reach in case they need assistance. R102 is admitted on [DATE] with diagnosis in part but not limited to anemia, type 2 diabetes mellitus with other circulatory complications, generalized osteoarthritis, overactive bladder. A focused care plan for potential complications related to cerebral vascular accident with left hemiparesis indicated interventions including call light within reach dated 8/25/22. On 1/16/25 at 12:35 PM, V2 (Director of Nursing) said that all call lights should be placed within residents reach and answered promptly by any staff available. The call light should be within reach in case the resident needs an assistance. Facility's policy on Call light revisions 2/2/18. Purpose: To respond to residents requests and needs in a timely and courteous manner. Guidelines: 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 145969 Page 4 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents (R68) reviewed for abuse in a sample of 36. Residents Affected - Few Findings include: On 1/15/2025 at 9:40am R68 said that R93 was her roommate in December and had accused her of taking a blanket and slapped her twice then scratched her on the nose. R93 was moved to another room on the same unit which she must come pass several times a day to smoke, and other activities, a couple of days ago R93 was blocking the hallway and she asked her can she come pass, and R93 started yelling at her and said go around and don't touch my chair. On another occasion R93 noticed R68 wheeling past by the nurse's station, and yelled out profanity saying get away from me now). R68 said I am not afraid of R93 but would like her to stop yelling at me when I'm wheeling past, I don't know why R93 is still on this floor she had an issue with another roommate. R68 said she spoke with the social worker and informed her about how R93 yells at her and the social worker said, that's just how she is. On 1/16/2024 at 10:30am V28(Social Worker) said she did follow up with R68 to ensure she was ok, and she said she was doing great and never mentioned that R93 was yelling at her. On 1/16/2025 at 12:00pm V35 (Certified Nurse's Assistant), said I am familiar with R68 and R93, R68 is a nice lady very approachable alert and oriented times three she smokes a lot but other than that she is a good resident. R93 is alert with periods of confusion and has been aggressive with several roommates she will accuse them of taking her items and will become aggressive if no-one stops her, she's had several roommates in the past. I was not on duty when R68 and R93 had an altercation on 9/10/2024 or 12/27/2024. On 1/16/2025 at 1:55pm V2(Director of Nurses-DON) said R68 is alert and oriented times three, she likes to smoke. R68 and R93 were roommates until an altercation occurred in December on the 27th and R93 scratched R68 on the nose she was confused and accused R68 of taking her blanket. R93 was sent out to the hospital and upon returning she was placed in a private room up front on the same hallway. R93 did have an altercation with a previous roommate on 9/10/2024, she was not sent out, the roommate said that R93 was confused about her belongings and felt safe. On 1/16/2025 V1(Administrator -Abuse Coordinator) said he was not familiar with R68 or R93 until the altercation on 12/27/2024 that resulted in R68 obtaining a scratch on her nose and R93 being transferred to the hospital and upon returning R93 was placed in a private room on the same hallway. I was not aware that R68 had complained about R93 and launched a full investigation, R93 is now moved to another floor. The altercation on 9/10/2024 was about R93 being confused of her belongings and the roommate said according to the incident that she felt safe, and no move was made. On 1/17/2025, at 9:30am, V45(Certified Nurse's Assistant-CNA), said that she was R93 CNA the day the altercation occurred on September 10, 2024, but was not in the room and that R93 is very confused at times and does accuse her roommates of taking her blanket and other items, she can become argumentative with her roommate and staff. On 1/17/2025, at 9:40am, V44(Certified Nurse's Assistant-CNA), said she is familiar with R68 and R93 and she was their CNA, the evening the altercation occurred on 12/27/2024 she was not in the room, 145969 Page 5 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R68 came to the nurse's station saying that R93 had scratched her nose and accused her of taking a blanket. R93 was sent to the hospital and upon returning placed in another room on the same unit. R93 can become confused, R68 is alert and oriented times three. A care plan dated 1/15/2025 indicates R68 has a diagnosis of schizoaffective disorder, anxiety disorder and absence of left and right foot, a focus of abuse and neglect and exploitation trauma, goal to be treated with respect, sensitivity, dignity and feel safe while I live here in the facility. An intervention to report any verbalization of abuse or neglect to administrator immediately revised on 12/30/2024. A care plan dated 12/30/2024 with a focus of R93 has the potential to be physically aggressive related to swing at others and make contact, goal demonstrate effective coping skills, communication to provide physical and verbal cues to alleviate anxiety. A focus I had potential to be verbally aggressive related to I cuss at others and falsely accuse them of taking my belongings, a goal demonstrates effective coping skills, an intervention monitor resident for behaviors and redirect as needed. On 1/16/2025 V3 (Assistant administrator) refused surveyor to have a copy of the incident on 9/10/2024 and 12/27/2024. Facility Policy: Resident's Rights for people in long term care facilities. Your rights to safety: You must not be abused, neglected, or exploited by anyone-financially, physically, verbally, mentally, or sexually. Abuse Prevention and reporting-Illinois Revisions on 10/24/22 This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation or property and mistreatment of residents. The of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services and mistreatment of residents. Protection of Residents: The facility shall take steps necessary to ensure the safety of residents including but not limited to the separation of the residents. 145969 Page 6 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide nail care to a dependent resident. This deficiency affects one (R55) of three residents in the sample of 36 reviewed for Activity of Daily Living (ADL) Program. Residents Affected - Few Findings include: On 1/15/25 at 10:18AM, Round made with V2 Director of Nursing and V17 Assistant Director of Nursing to R55. Observed R55 lying in bed with call light within reach. She is alert and responsive but confused. Observed bilateral fingernails are long and dirty. There is black matter underneath the resident's long fingernails. V2 said that CNAs (Certified Nursing Assistant) and Nurses should provide nail care- including cleaning and trimming of fingernails to R55 as part of ADLs program. R55 is admitted on [DATE] with diagnosis listed in part but not limited to non-traumatic intracerebral hemorrhage in hemisphere, subcortical, Type 2 Diabetes Mellitus, Adult failure to thrive. Comprehensive care plan indicated she has an ADL self-care /mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day related to osteoarthritis, weakness. She has impaired cognitive function/impaired thought processes related to difficulty making decisions, impaired decision making. Facility's policy on Nail care revision 1/25/28 indicated: Guidelines: 1. Observe condition of resident nails during each time of bathing. Note cleanliness, length uneven edges, hypertrophied nails. 4. After bathing, use orange stick and clean debris from around and under finger and toenails. 5. Trim toenails carefully in a straight fashion and fingernails in an oval fashion avoiding tissue after bathing or when needed. Be sure nails are soft before trimming. Additional soaking in warm soapy water may be necessary to soften nails. 6. Licensed Nurse is to trim diabetic resident's nails. Activities of Daily Living (ADLS) indicates: Grooming- maintaining personal hygiene, including planning the task and gathering supplies combing and or styling hair, face, and hands, brushing teeth, shaving, or applying makeup, oral hygiene, self-manicure (safety awareness with nail care), and or application of deodorant or powder. 145969 Page 7 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 implement manufacturer's recommendation in using low air loss mattress to residents with multiple stage 4 and unstageable pressure ulcer. This deficiency affects all four (R5, R83, R147 and R185) residents in the sample of 36 reviewed for Wound/Pressure ulcer Prevention Management. Residents Affected - Some Findings include: 1. On 1/14/25 at 7:16AM, Rounds made to R147 with V9 Nursing Supervisor. Observed R147 lying in bed with Low air loss mattress. Observed flat sheet with cloth pad over the mattress. V9 said that R147 should only have flat sheet over the mattress. R147 is admitted on [DATE] with diagnosis listed in part but not limited to Respiratory failure with hypoxia, Parkinson disease, Dementia, End stage renal disease, Multiple pressure ulcers to different body parts-sacral/buttocks, elbows, and heels. Active physician order sheet indicated Left anterior leg- clean with wound cleanser, pat dry with gauze, every Tuesday, Thursday, and Saturday and as needed. Left elbow-clean with wound cleanser, pat and dry with gauze, apply xeroform and cover with dry dressing, every Tuesday, Thursday, and Saturday and as needed. Right elbow- clean with wound cleanser, pat and dry with gauze, apply Medi honey and cover with comfort foam, every Tuesday, Thursday, and Saturday and as needed. Right heel- clean with wound cleanser, pat and dry with gauze, apply skin prep and cover with foam border, every Tuesday, Thursday, and Saturday and as needed. Right toe- clean with wound cleanser, pat and dry with gauze, apply skin prep and leave it open to air, every Tuesday, Thursday, and Saturday and as needed. Sacrum and right buttocks- clean with Dakin's, pat and dry with gauze, apply Santyl external ointment 250unit /gm and cover with waterproof foam, daily and as needed. Most recent Braden/skin assessment dated [DATE] indicated that he is at risk for skin impairment. Comprehensive care plan indicated that he has impaired skin integrity. Intervention: Follow facility policies/protocol for the prevention/treatment of skin breakdown. Wound assessment done by V10 WCP dated 1/14/25 indicated: Stage 3 pressure ulcer on left elbow 0.3cmx 0.3cmx 0.2cm. Small amount of serosanguinous drainage noted. The wound is limited to skin breakdown. Unstageable pressure ulcer on right gluteus- 2.8cmx 0.7cmx 0.1cm. Subcutaneous tissue exposed. Small amount of serosanguinous drainage noted. 1-33% granulation within wound bed. 67-100% amount of necrotic tissue within the wound bed including adherent slough. Stage 3 pressure ulcer on right elbow- 0.9cm x 1cmx 0.5cm. Subcutaneous tissue exposed. Small amount of serosanguinous drainage noted. 1-33% granulation within wound bed. 67-100% amount of necrotic tissue within the wound bed including adherent slough. Pressure ulcer on right calcaneus- 2.6cmx 3.6cm x0cm. The wound is limited to skin breakdown. Pressure ulcer on right great toe- 0.4cm x0.5cm x0cm. The wound is limited to skin breakdown. Stage 3 pressure ulcer on Sacrum-1.8cm x0.5cmx 0.5cm. Subcutaneous tissue exposed. Small amount of serosanguinous drainage noted. 34-66% granulation within the wound bed. 1-33% necrotic tissue within the wound bed including adherent slough. Full thickness abrasion to Left posterior lower leg1.4cm x0.7cm x0.1cm. The wound is limited to skin breakdown. 2. On 1/14/25 at 7:20AM, Rounds made to R83 with V8, Agency Nurse. Observed R83 lying in bed with tracheostomy tube on room air. She has low air loss mattress with flat sheet and cloth pad over the mattress. R83 said that she has bed sores on her buttocks. V8 said that resident on low air loss mattress should have flat sheet over the mattress. 145969 Page 8 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R83 is re-admitted on [DATE] with diagnosis listed in part but not limited to Chronic respiratory failure, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, tracheostomy, Gastrostomy. Active physician order sheet indicates: Sacrum and Left buttocks, cleanse with Dakin's quarter strength solution and pat dry. Apply calcium alginate and cover with waterproof dressing everyday shift and as needed for wound care. Most recent Braden/skin assessment dated [DATE] indicated he is at risk for skin impairment. Comprehensive care plan indicated she has impaired skin integrity. Intervention: Follow facility policies/protocol for the prevention/treatment of skin breakdown. Wound assessment done by V10 WCP dated 1/14/25 indicated: Stage 4 pressure ulcer on Sacrum- 8.2cm x2.4cm x 2cm. Subcutaneous tissue exposed. Medium amount of serosanguinous drainage noted. 67-100% granulation within the wound bed. Pressure redistribution mattress per facility policy/protocol. On 1/14/25, at 9:13AM, V2, Director of Nursing (DON), said that resident on low air loss mattress should only be on flat sheet over the mattress as per manufacturer recommendation. No multilayer of linen over the mattress. On 1/14/25, at 10:45AM, V10, Wound Care Physician, said that resident on low air loss mattress should only have flat sheet over the mattress as manufacturer recommendation. Multilayer of linens will impede the purpose of low air loss mattress. On 1/15/24, at 10:00AM, V2 DON said that they don't have policy on low air loss mattress usage. Facility unable to provide policy on using Low air loss mattress Facility's policy on Pressure ulcer Prevention revisions: 1/15/18 indicated: Purpose: To prevent and treat sores/pressure injury Guidelines: 9. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for resident who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds. 3. On 01/15/2025 at 8:08AM during observation, R5's low air loss mattress machine did not have any light indicators turned on. On 01/15/2025 at 8:08AM during observation with V6 (Licensed Practical Nurse), R5's low air loss mattress machine did not have any light indicators turned on. On 01/15/2025 at 10:46AM during observation with V32 (Wound Care Coordinator), R5's low air loss mattress machine did not have any light indicators turned on. On 01/15/2025, at 8:08AM, during interview with V6, (Licensed Practical Nurse), V6 stated that R5's low air loss mattress machine should have light indicators turned on to know the current setting of the low air loss mattress. V6 also stated that wound care team checks the low air loss mattresses settings daily and should have noticed that R5's low air loss machine did not have any light indicators turned on. V6 stated that when the low air loss mattress is deflated or the machine is faulty, the maintenance or the wound care team should have been informed to address it. 145969 Page 9 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 01/15/2025, at 10:46AM, during interview with V32, V32 stated that each floor has a wound nurse assigned. V32 stated that the wound nurses check and make sure that all low air loss mattresses are in the right setting. V32 also stated that she was not aware that R5's low air loss mattress machine did not have any light indicators turned on, and if she did, she could have addressed it immediately. Review of R5's Braden Scale for Predicting Pressure Sore Risk dated 12/05/2024 indicated a score of 15 which is at risk for developing pressure wounds. Review of R5's Order Summary Report dated 01/15/2025 indicated admission date of 06/13/2023, diagnoses of not limited to Irritant Contact Dermatitis due to fecal, urinary or dual incontinence and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, and order for low air loss mattress for wound management with order date of 09/11/2023. Review of R5's care plan revised on 11/19/2024 indicated R5 has impaired skin integrity noted to buttocks and right ischial tuberosity, and interventions including low air loss mattress for wound management. 4. On 01/17/2025, at 7:41AM, during observation, R185 did not have heel protectors, R185's low air loss mattress dial for setting was noted at >350, and R185's low air loss mattress machine had a small written note that reads 136.5 taped on it. On 01/17/2025, at 8:01AM, during observation with V26 (Licensed Practical Nurse), R185 did not have heel protectors, R185's low air loss mattress dial for setting was noted at >350, and R185's low air loss mattress machine had a small written note that reads 136.5 taped on it. V26 proceeded to turning the dial to between 120 and 150. On 01/17/2025, at 8:01AM, during interview with V26, V26 stated that R185 should have heel protectors, R185's low air loss mattress dial for setting should be between 120 and 150 since there is a note that says R185 weighs 136.5. On 01/15/2025 at 10:46AM during interview with V32 (Wound Care Coordinator), V32 stated that each floor has a wound nurse assigned. V32 stated that the wound nurses check and make sure that all low air loss mattresses are in the right setting. Review of R185's Braden Scale for Predicting Pressure Sore Risk dated 11/30/2024 indicated a score of 17 which is at risk for developing pressure wounds. Review of R185's Wound Visit Report dated 01/14/2025 indicated plan for pressure relief/offloading includes pressure redistribution mattress per facility policy/protocol and offload heels with heel protectors. Review of R185's care plan revised on 12/10/2024 indicated R185 has impaired skin integrity, admitted with skin impairment to left heel, right heel and sacrum, and interventions including minimize pressure over boney prominences and pressure reducing mattress. Review of R185's Order Summary Report dated 01/15/2025 indicated admission date of 11/29/2024 and diagnoses of not limited to severe protein-calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pressure ulcer of right heel unstageable, 145969 Page 10 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0686 pressure ulcer of sacral region stage 3, and pressure ulcer of left heel stage 3. Level of Harm - Minimal harm or potential for actual harm Facility unable to provide policy on using Low air loss mattress Review of facility's policy on Pressure ulcer Prevention revised on 1/15/18 indicated: Residents Affected - Some Purpose: To prevent and treat sores/pressure injury Guidelines: 9. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for resident who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds. 145969 Page 11 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure fall preventive measures were implemented to residents who are at risk for fall and history of falls. The facility also failed to change the fall intervention with each fall incident in a timely manner. This deficiency affects all four (R147, R148, R191 and R261) in a sample 36 reviewed for Fall prevention program. Findings include: 1. On 1/14/25, at 7:02AM, Observed R191 lying in bed on high position (surveyor waistline level) with bilateral floor mat. He has right arm flexion contracture. His call light and bed control are placed on his bedside dresser, not within reach. Called V9 Nursing supervisor and showed observation made. V9 said that R191's call light should be within reach and his bed should be in the lowest position while on bed. She took the call light and placed within R191's reach. She then took the bed control and placed the resident on the lowest position. R191 is admitted on [DATE] with diagnosis listed in part but not limited to non-traumatic intracerebral hemorrhage in hemisphere subcortical, Hemiplegia and hemiparesis following non traumatic intracerebral hemorrhage affecting right dominant side, Seizures, Cerebral edema, Aphasia, Dysphagia, Gastrostomy. Most recent fall assessment dated [DATE] indicated that he is at risk for fall. Comprehensive care plan indicated that she is at risk for fall and injury related falls. Intervention: Ensure the resident call light is within reach and encourage the resident to use it for assistance as needed. Follow fall protocol. Provide floor mats. He has history of witnessed fall incident in his room. 2. On 1/14/25 at 7:12AM, Rounds made to R261 with V9 Nursing Supervisor. Observed R261 lying in bed with language barrier. He speaks Spanish and trying to gesture to elevate his head. Observed call light is on the floor. V9 said that resident's call light should be within reach. She picked up the call light and placed within R261's reach. R261 was admitted on [DATE] with diagnosis listed in part but not limited to hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side, Respiratory failure, Type 2 Diabetes Mellitus. Comprehensive care plan indicated that he is at risk for falls and injury related to falls. Intervention: Ensure call light is within reach and encourage resident to use it for assistance as needed. Follow facility fall protocol. Most recent fall assessment dated [DATE] indicated he is at risk for fall. Most recent unwitnessed fall incident dated 1/13/25 indicated he was found lying on the floor beside his bed. 3. On 1/14/25, at 7:16AM, Rounds made to R147 with V9, Nursing Supervisor. Observed R147 lying in bed in high position with a floor mat on right side of his bed. His call light is on the floor. V9 Nursing supervisor said that call light should placed within resident reach and the bed should be in lowest position. She said that there should be a floor mat on both sides of the bed. R147 was admitted on [DATE], with diagnosis listed in part but not limited to: Respiratory failure, Parkinson's disease, Dementia, End stage renal disease, Multiple pressure ulcers. Comprehensive care plan indicated he is at risk for fall and for injury that may result from it. Interventions: Reachable call light and personal items within reach. Floor mats. Most recent fall assessment dated [DATE] indicated that he is at risk for fall. Most recent unwitnessed fall incident dated 12/26/24 145969 Page 12 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0689 indicated he was found lying beside his bed. Level of Harm - Minimal harm or potential for actual harm On 1/14/25, at 9:13AM, V2, Director of Nursing (DON), said that some of the fall prevention interventions for a resident at risk for falling are call light should be within reach, bilateral floor mats and bed on the lowest position. Residents Affected - Some On 1/14/25, at 1:39PM, V15, Fall Coordinator, said that she is responsible for the fall prevention program of the facility and does the fall investigation after each fall with IDT (Interdisciplinary team) to develop new intervention to prevent re-occurrence of fall. Fall preventive measures of the facility are identified resident at risk for fall, bed on the lowest position when resident in bed, Bilateral floor mats, call light, and personal items within reach, rounding every 2 hours. On 1/16/25, at 11:05AM, review medical records of R147, R191 and R261 with V15 Fall coordinator and informed above observations and concerns. V15 said that resident's call light should be within reach, bed should be in the lowest position and R147 should have floor mats on both side of the bed. Facility's Fall prevention Program revision 11/27/17 indicated: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Guidelines: Care Plan incorporates: *Address each fall *Interventions are changed with each fall, as appropriate Standards: *Safety interventions will be implemented for each resident identified at risk. *Accident/incident reports involving falls will be reviewed by the IDT to ensure appropriate care and services were provided and determine possible safety interventions. Fall/safety interventions may include but not limited to: *The nurse call device will be placed within the resident's reach at all times. 4. On 1/14/25, at 10:15 AM, V15 (Fall Coordinator) said that care plans are updated within 24 hours after fall incident occurs, and that the interdisciplinary team fall committee meeting note assessment is completed within 72 hours. V15 said that when an assessment is in progress, or not locked, it means it is not completed and V15 does not know when R148's care plan or fall committee meeting note was completed. V15 was made aware that R148 had a fall on 12/27/24 and care plan had no intervention updated. V15 said that she will look into it and print out care plan. 145969 Page 13 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/14/25, at 12:39 PM, V15 presented a fall care plan for R148 with intervention initiated on 12/27/24 with created date on 1/14/25. Also presented fall committee meeting note assessment with completed date 1/14/25. On 1/14/25, at 1:45 PM, V2 (Director of Nursing) was made aware of above findings and said that after a fall incident occurs the care plan is reviewed the next day or within 24 hours and updated with new interventions. The interdisciplinary team reviews for root cause analysis within 24-48 hours for completion. V2 said that R148's care plan should have been updated within 24 hours and not on 1/14/25. On 1/16/25, at 12:09 PM, V38 (MDS nurse) said after reviewing the care plan for R148, the fall care plan intervention was created on 1/14/25. V38 said that the care plan should have been revised within 24 hours after fall. R148 was admitted on [DATE] with diagnosis in part but not limited to type 2 diabetes mellitus without complications, generalized anxiety disorder, history of falling, other lack of coordination. admission fall assessment indicated that he she is at high risk for falls. Comprehensive care plan indicated that she is at high risk for falls due to requiring assistance with activities of daily living, possible medication side effects, history of falls, and incontinence. R148 most recent unwitnessed fall dated 12/27/24 indicated that she was observed on the floor in her room. 145969 Page 14 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow physician's order for oxygen administration affecting 1 of 2 (R53) residents reviewed for oxygen use in a sample of 36. Residents Affected - Few Findings Include: On 01/14/25, at 8:05 AM, R53 was in bed with oxygen (O2) on per nasal cannula (NC) running at 1L per minute. Physician order checked with V4 (Licensed Practical Nurse/LPN) and indicated O2 at 2L/NC and titrate to 4L/NC. V4 said R53's oxygen should be at 2L/NC. On 1/14/2025 at 8:32 AM, V2 (Director of Nursing) said physician's orders should be followed and O2 in use signage should be posted by the door. Order Summary Report: Diagnoses: Metabolic Encephalopathy; Respiratory Failure, Unspecified with Hypoxia; Shortness of Breath; Unspecified Asthma, Uncomplicated; Heart Failure, Unspecified Order Date 12/16/2024 May start O2 at 2L/NC and titrate to 4L/NC to maintain O2 SATS above 90% PRN Care Plan: R53 use oxygen as ordered, R53 at risk for complications related to its use. Intervention: Administer oxygen as ordered. Give medications as ordered by physician. Policy and Procedure Physician Orders-Entering and Processing, Revisions: 1/13/18 Purpose: To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders. Guidelines: 1. When receiving physician's orders by telephone: Enter the order into the resident's chart under order tab and according to the instructions for the type of order that is received. Be sure to include a diagnosis or indication for use. If a diagnosis is not in the resident's clinical record, ask the physician for a diagnosis. Medication orders should include: 145969 Page 15 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0695 1. Route 2. Dose 3. Time (s) 4. Frequency 5. If a treatment, be sure to put in the Level of Harm - Minimal harm or potential for actual harm Directions the specific area(s) to be treated. Residents Affected - Few 145969 Page 16 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review and interview the facility failed to ensure that each resident medication regimen was free from unnecessary medication for 1 of 2 resident's (R91) reviewed for unnecessary psychotropic medication in a sample of 36. Findings include: On 1/17/2025, at 12:00pm, V2, (Director of Nursing-DON), said the assistant director of nursing and the director of nursing is responsible for following up on the pharmacy recommendations. On 1/17/2025, at 12:10pm, this surveyor and V2 reviewed a consult pharmacist recommendation to prescriber document dated 10/1/2024 that indicated R91 Olanzapine 2.5 milligrams for bipolar to be discontinued to minimize somnolence. The physician response agreed and signed. A medication administration record dated October 2024, November 2024, December 2024, and January 2025 all indicated that Olanzapine 2.5mg was signed out daily by the nurse at 9am and administered to R91. An Order Summary Report dated January 16, 2025, indicates that R91 has Olanzapine 2.5 mg ordered on 9/19/2024 for unspecified dementia. Facility Policy: Psychotropic Medication-Gradual Dose Reduction revised on 2-1-2018. Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice and are prescribed at the lowest therapeutic dose to treat such conditions. Guidelines: D) Side effects and dosage of the medication shall be described. Monitoring: The licensed pharmacist will review the resident's drug regimen monthly and document findings. The pharmacist will report any irregularities to the Director of Nursing. The director of Nursing will notify the direct licensed staff to notify attending physician as necessary. 145969 Page 17 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 4. On 1/14/2025 at 7:45AM, medications, Geri-lanta (Mylanta) and Artificial tears eye drop on top of R4's bedside table. R4 said staff is aware of medications at bedside. Nurse leaves it for her to take. R4 said she takes Geri-lanta after each meal and uses her eye drop when needed. On 1/15/2025 at 12:40 PM, R4's Geri-lanta and Artificial Tears eye drop was on her bedside table. R4 said she takes Geri-lanta at least three times a day with every meal and administer her eye drops at least five to six times daily. R4 said morning nurse is aware of medications at bedside. On 1/15/2025 at 12:42 PM, V24 (Licensed Practical Nurse/LPN) said she is aware of R4's medications at bedside and has an order to keep it at bedside. V24 checked Physician's order and confirmed of medications order but without the order of may keep at bedside. V24 said the medications of R4 should not be at bedside. On 1/14/2025 at 10:25 AM, V2 (Director of Nursing) said medication should not be at bedside unless there is a physician order, assessment, and care plan. admission Record: Diagnosis Information: Gastro-Esophageal Reflux Disease without Esophagitis; Chronic Pain Syndrome; Erythema Intertrigo Order Summary Report: Artificial Tears Solution 0.4%(Hypromellose) Instill 1 drop in both eyes at bedtime for dry eyes (Order date: 10/10/2024) Mylanta Suspension 200-200-20 MG/ML (Alum & Mag Hydroxide-Simeth) Give 15 ml by mouth every 6 hours as needed for Gerd (Order date: 10/15/2020) Medication Self-Administration Assessment completed and signed on 1/14/2025 by V2 Care Plan: Revision date 1/14/2025 Focus: The resident expresses the desire to self-administer her Mylanta and has been assessed as appropriate: Interventions: Obtain order from physician. Policy and Procedure Self- Administration of Medication Purpose: To establish guidelines concerning the self-administration of drugs. General Guidelines: 145969 Page 18 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0761 Level of Harm - Minimal harm or potential for actual harm 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician. 2. Should the resident's attending physician permit the resident to administer his/her medication(s), the following condition should apply: Residents Affected - Some c. A self-administration of medications assessment will be completed that indicates that the resident is capable of self-administering drugs. Based on observation, interview and record review, the facility failed to monitor self-administration medication management, medication refrigerator temperature log, and label insulin with open date and follow pharmacy/manufacturer's recommendation on discarding for one of five medication carts (3rd floor medication cart), and one of two medication room storage (2nd floor medication room) observed for medication storage and labeling. This failure also affected one of one resident (R4) reviewed for medication self-administration. Findings include: 1. On 01/14/25, at 07:15 AM, observed medication cart on 4th floor by nurse's station unlocked with medications on top of cart. On 1/14/25, at 7:20 AM, V33 (Licensed Practical Nurse) said that cart should not be left open and unattended because residents can easily access the medications. 2. On 1/15/25, at 11:05 AM, during observation with V24 (Licensed Practical Nurse) on 3rd floor medication cart and medication storage room had the following: 1. R56's opened Insulin glargine pen with open date 11/14/24. Manufacturer's storage recommendation includes throwing away opened insulin glargine pen after 28 days. 2. R139's opened Insulin Lispro vial with no open date and second Insulin Lispro vial with open date 12/15/24. 3. R139's opened Insulin glargine vial with open date 11/8/24. 4. Expired house stock Aspirin 325mg bottle expiration date 10/2024. 5. Medication storage room refrigerator with 1 container of personal food stored inside. On 1/15/24, at 11:09, V24 said that expired insulin should be removed from cart and discarded, because if administered to residents it will not be effective, and no personal food inside medication refrigerator should be stored. 3. On 1/15/25, at 11:20 AM, during observation with V26 (Licensed Practical Nurse) on 2nd floor medication storage room had the following: 1. R5's Semaglutide pen injector with no open date. 145969 Page 19 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0761 2. Refrigerator temperature log last completed on 1/12/25. Level of Harm - Minimal harm or potential for actual harm On 1/15/25, at 11:24 AM, V26 said that all open medication should have an open date to track when it should be discarded as insulin re good for 28 days after opening date. V26 said refrigerator temperature logs are to be monitored daily and recorded by nurses. Residents Affected - Some On 1/15/25, at 11:45 AM, V2 (Director of Nursing) was made aware of above findings. V2 said that all insulin should have an open date as well as an expiration date, as insulin is good for 28 days after open date. Medication refrigerator temperature logs are to be checked daily by nurses and recorded and no personal food should be stored inside medication refrigerator. All house stock medications should be discarded if expired. V2 said that medication carts should be kept locked, and no medications left on top of cart to avoid any risk of residents or other staff/ family obtaining access to cart. Review of R56's order summary report dated 1/15/25 indicated admission date of 09/17/20 and diagnosis in part but not limited to type 2 diabetes mellitus with other circulatory complications, diabetes mellitus due to underlying condition with hyperglycemia. It also indicated order for Insulin glargine with order date of 11/25/2024. Review of R139's order summary report dated 1/15/25 indicated admission date of 11/27/24 and diagnosis in part, but not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease, unspecified glaucoma, hyperlipidemia unspecified. It also indicated order for Insulin Lispro with order date of 12/05/2024. Review of R5's order summary report dated 1/15/25 indicated admission date of 6/13/23 and diagnosis in part with but not limited to type 2 diabetes mellitus with diabetic chronic kidney disease, hyperlipidemia unspecified, long term (current) use of insulin. It also indicated order for Semaglutide insulin with order date 1/15/25. Facility's Policy on Medication Storage revisions:2-5-18;7-2-19 Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes, and needles. Guidelines 3. General Storage Procedures: 3.2 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 3.5 Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals are stored. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication as a shortened expiration date once opened. 145969 Page 20 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0761 Facility's Policy on Storage of Medication Policy #4.1 Pharmscript Level of Harm - Minimal harm or potential for actual harm Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Residents Affected - Some Procedures: 5. The facility should maintain a temperature log in the storage are to record temperatures at least once a day. Expiration Dating (Beyond -use dating) 2. Drugs dispensed in the manufacturer's original container will be labeled with the manufacture's expiration date. 8. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. 145969 Page 21 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

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 discarding food products before or on expiration date affecting all 196 residents receiving food from the kitchen. The facility also failed to ensure resident refrigerators have recorded temperature logs affecting 4 of 6 (R6, R53, R140, R168) residents reviewed for resident refrigerator in a sample of 36. Findings Include: 1. On 1/14/2025 at 6:20AM, during kitchen initial tour, the container of multiple use for Flour, Thickener, and Sugar has the used by date of 9/24/2024. All containers were less than half full. V21 (Cook) said it was recently filled but forgot to change the date on the label. V21 said yesterday was the last time the content of these containers was used. On food shelves, four cartons of Mildly Thick - Nectar Consistency (46 FL OZ) were expired, three cartons with used by date of 12/3/2024 and one carton with used by 11/12/2024. V21 said all should have been removed from the shelf. On another food shelves, individually pack of hot sauce, sweet relish, tartar sauce, and horseradish stored on individual containers with the use by date of 1/6/2025. V21 said the individual packs should have been removed and replaced. On 1/14/2025 at 9:30 AM, V1 (Administrator) said food and food products need to be discarded on or before expiration date. 2. On 1/14/2025 between 7:30 AM - 8:30 AM during the initial facility tour, R53, R140, and R168 all have refrigerator in their room. All refrigerators were without the temperature log to monitor daily. On 1/14/2025 at 9:30 AM, V1 (Administrator) said unit refrigerator in residents' room should have a temperature log monitored daily. Guideline & Procedure Manual 2020 Food Storage (Dry, Refrigerated, and Frozen) Guideline: Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. c. Discard food that has passed the expiration date. Facility unable to provide policy for Resident Refrigerator Monitoring. 145969 Page 22 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3. On 1/14/25 at 7:45 AM, observed R6 in bed alert and verbal. R6 refrigerator observed with temperature log last dated on 1/7/25. R6 said that the staff is the one who checks the refrigerator and said he does not remember when the last time was it was checked. R6's refrigerator contained 1 bottle of mustard, 1 can of parmesan cheese, 2 bottles of ketchup, 1 bottle of ranch sauce, 3 cups of pudding, 1 bottle of cocktail sauce, and 1 container of butter spread. On 1/14/25 at 8:02 AM, V34 (Housekeeper) said that housekeepers are the ones who check the refrigerators to make sure the temperature is within range daily. V34 said the range is between 38-43 degrees Fahrenheit and said does not know why it has not been checked but will fill out the log. V34 opened the refrigerator and check temperature with reading of 30 degrees Fahrenheit. V34 stated that she will need to report it to V25 (Housekeeper Manager) due to it being below the normal ranges and food inside the refrigerator not labeled. On 1/14/25 at 8:18 AM, V25 said that the refrigerator temperature logs are checked daily to ensure proper function and temperature. V25 said that all food inside R6 refrigerator will be discarded due to the temperature below range and does not know how long food has been sitting inside the refrigerator. On 1/14/25 at 9:20 AM, V2 (Director of Nursing) made aware of above findings, V2 said that refrigerator temperature logs are to be checked daily by housekeeping, if the temperature is not within range, then maintenance will check and adjust temperature. V2 said that all food inside R6 refrigerator should be discarded. 145969 Page 23 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

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 use appropriate infection control practices after using respiratory treatment and when performing high contact resident care to resident on Enhanced barrier precaution. This deficiency affects two (R83 and R261) residents in the sample of 36 reviewed for Infection control Program. Residents Affected - Few Findings include: 1. On 1/14/25 at 7:12AM, rounds made with V9 Nursing supervisor to R261. Observed R261 lying on bed. He has oxygen via nasal cannula at 6 liters per minute. Observed nebulizer machine with tubing connected to nebulizer tubing mask found exposed on the floor. V9 Nursing supervisor said that nebulizer mask should be placed in plastic bag and stored in bedside drawer. R261 is admitted on [DATE] with diagnosis listed in part but not limited to hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side, Respiratory failure, Pleural effusion, Type 2 Diabetes Mellitus. Active physician order sheet indicates: Ipratropium-albuterol solution 0.5-2.5 (3) mg/3ml inhales every 4 hours as needed for shortness of breath or wheezing via nebulizer. 2. On 1/14/25 at 7:20AM, Rounds made to R83 with V8 Agency Nurse. Observed R83 lying in bed with tracheostomy tube on room air. She has oxygen at bedside. Observed nebulizer mask connected to machine exposed and uncovered. V8 said that nebulizer mask should be place in plastic bag when not in used. R83 was re-admitted on [DATE] with diagnosis listed in part, but not limited to, Chronic respiratory failure, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, tracheostomy, and Gastrostomy. Active physician order sheet indicates: Ipratropium-albuterol solution 0.5-2.5 (3) mg/3ml inhale orally every 4 hours as needed for shortness of breath or wheezing via nebulizer. On 1/14/25, at 9:13AM, V2 Director of Nursing (DON) said that nebulizer mask should be placed in plastic bag when not in used for infection control. On 1/14/25, at 10:43AM, V32 Wound Care coordinator informed surveyor to proceed to R83's room because the wound care team are with V10 Wound Care Physician (WCP) providing wound care assessment and treatment. Observed Enhanced Barrier Precaution (EBP)posted outside R83's door. Observed resident lying in bed, uncovered and exposed. She was wearing a gown and an adult brief. V11 Wound Care Nurse and V12 CNA are both wearing gloves preparing R83 for wound care. V12 CNA was holding a clean disposable brief to change R83's soiled brief. V10, WCP, was observed inside the room with his laptop wearing gloves, reviewing his wound notes for R83. Surveyor asked V11, WCN, of their expectation for resident on EBP during wound care. V11 WCN said that they should wear gloves, gown and mask when providing wound care or any direct care/contact of resident on EBP. V11 WCN informed V12 CNA and V10 WCP to wear PPE. On 1/14/25 at 11:11AM, V14 Unit Manager said that nursing staff should wear PPE for contact isolation when providing wound care or any direct contact to resident on EBP. 145969 Page 24 of 25 145969 01/17/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0880 On 1/14/25, at 1:58pm, V16, Infection coordinator, said that staff should be wearing PPE when providing direct care such as wound care to a resident on EBP. Level of Harm - Minimal harm or potential for actual harm Facility's policy on Nebulizer Medication administration review/revisions: 10/9/18 indicated: Residents Affected - Few Guidelines: 23. When nebulizer equipment is completely dry, store in a plastic bag within the resident's name and the date on it. Facility's policy on Enhanced Barrier Precaution review/revisions: 4/8/24 indicated: Purpose: To reduce risk of transmitting multi-drug-resistant organism (MDRO) and targeted MDRO when contact precaution do not apply for residents identified as higher risk. Enhanced Barrier Precaution (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organism that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precaution and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. For resident for whom EBP are indicated, EBP is employed when performing the following high contact resident care, especially when care is handled: *Providing hygiene *Changing briefs or assisting with toileting *Wound care: any chronic skin opening requiring a dressing 145969 Page 25 of 25