Health inspection·May 2, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to update resident care plans to accurately identify isolation needs. These failures have the potential to affect 4 residents (R1, R2, R4, and R5) reviewed for isolation. Findings include: Record review of R1's physician orders document an active order for contact isolation precautions. Record review of R1's care plan does not document care planning for R1's isolation needs. Record review of R2's physician orders document an order for contact and droplet isolation precautions. Record review of R2's care plan does not document that the isolation needs were care planned during R2's stay in the facility. Record review of R4's physician orders document an active order for contact isolation precautions. Record review of R4's care plan does not document care planning for R4's isolation needs. Record review of R5's physician orders document an active order for contact isolation precautions. Record review of R5's care plan does not document care planning for R5's isolation needs. On 5/2/2025 at 12:14 PM, V2 (Director of Nursing) affirmed that when a resident is on isolation, the care plan must be updated to reflect their isolation status. Record review of facility policy titled, Care Plans (Comprehensive) (10/2022) documents in part, .Policy: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident . 5. Care plans are revised as changes in the resident's condition dictates. Page 1 of 3 145977 145977 05/02/2025 South Shore Rehabilitation 2425 East 71st Street Chicago, IL 60649

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure personal protective equipment (PPE) was readily available for use for residents that require enhanced barrier precautions and transmission-based precautions; failed to ensure linen cart was covered. These failures have the potential to affect 6 residents (R1, R4, R5, R6, R8, R9) reviewed for infection control. Residents Affected - Some Findings include: 1) On 5/2/2025 at 10:30 AM, enhanced barrier precaution signs (noting that providers and staff must wear gown/gloves when providing high-contact resident care activities) were noted on the doors to resident's rooms. No personal protect equipment (PPE) was noted to be readily accessible outside the rooms. V6 (Certified Nursing Assistant) affirmed that there was no PPE available for use. V6 stated that V6 would be unable to provide care to those residents due to the lack of required PPE. On 5/2/2025 at 10:32 AM, V2 (Director of Nursing) affirmed that there was no PPE available for the staff to use for residents that require enhanced barrier precautions for the resident's rooms. V2 stated, I (V2) think they (the staff) brought all the containers downstairs to refill them. Record review of facility provided document titled ENCHANCED BARREIR PRECAUTION (undated) documents in part that the four resident's rooms require enhanced barrier precautions. 2) On 5/2/2025 at 10:48 AM, a contact precaution sign (noted that everyone must clean their hand prior to entering/exiting the room, and don gown/gloves prior to entering the room) was noted to R1's door. No gloves were noted in R1's isolation bins. V11 (Psychosocial Rehabilitation Services Coordinator) observed the isolation bin on R1's door and affirmed that there were no gloves. V11 stated, there should be gloves in there, and it's missing hand sanitizer too. V11 walked down the hallway and approached V8 (Restorative/Rehab Nurse, Licensed Practical Nurse) and asked for gloves from V8's medication cart. V8 responded, I don't have any. V11 then grabbed the last box of gloves from a PPE bin located near the end of the hallway, (leaving that bin without gloves) and placed the box of gloves in R1's isolation bin. No hand sanitizer was placed in R1's isolation bin. 3) On 5/2/2025 at 11:15 AM, a contact precaution sign (noted that everyone must clean their hand prior to entering/exiting the room, and don gown/gloves prior to entering the room) was noted to R4's door. No gloves were observed in R4's isolation bin. V12 (Licensed Practical Nurse) observed R4's isolation bin and affirmed there were no gloves in the isolation bin. V12 stated, there are some here after entering the room to get to another box located inside the threshold of the room. 4) On 5/2/2025 at 11:17 AM, the first-floor linen cart was observed uncovered. V12 (Licensed Practical Nurse) stated that the linen cart should be always covered. V12 pulled the flap down to cover the linen cart and turned the cart's opening to the wall. V12 explained that covering the linen cart is important to ensure the linen remain clean and have less exposure to germs. Record review of facility policy titled, Isolation- categories for Transmission-Based Precautions (1/2024) documents in part Contact Precautions . Use personal protective equipment (PPE) appropriately, including gloves and gowns. Wear a gown and gloves for all interactions that may involve contact with the resident or the resident's environment. [NAME] PPE upon room entry and properly discarding before exiting the resident room is done to contain pathogens. The policy does not include 145977 Page 2 of 3 145977 05/02/2025 South Shore Rehabilitation 2425 East 71st Street Chicago, IL 60649

F 0880 procedures regarding the availability of personal protective equipment. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled, Infection Prevention and Control Program(1/24/24) documents in part, Mission of program: The primary mission is to establish and maintain an effective Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 5. A system for linen handling to prevent the spread of infection includes handling, storing, processing and transporting linen . Residents Affected - Some 145977 Page 3 of 3