Health inspection·February 6, 2025

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 wounds were cleansed and PPE (personal protective equipment) was worn in a manner to prevent cross contamination for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 3. Residents Affected - Few The findings include: R1's face sheet printed on 2/6/25 showed diagnoses including but not limited to metabolic encephalopathy, Down syndrome, and early onset Alzheimer's disease. R1's February 2025 physician order report showed an order for: Cleanse wounds on buttocks and apply calcium alginate and dressing everyday shift for wound. The same report showed an order for: Transmission based droplet isolation related to: MRSA (Methicillin resistant staphylococcus aureus) of sputum every shift. The same report showed an order for: doxycycline hyclate (antibiotic) oral tablet 100 milligrams two times a day for 6 days. On 2/6/25 at 10:01 AM, R1 was observed from the hallway lying in bed. The room door was wide open, and a sign was posted on the door showing STOP DROPLET PRECAUTIONS. The sign showed that everyone must have a mask and eye protection on while inside the room. At 10:18 AM, V3 (WCN/ICP-Wound Care Nurse/Infection Control Preventionist) and V5 (Licensed Practical Nurse) donned gloves and gowns to begin R1's dressing change. V3 did not wear a mask or eye protection. V5 wore a surgical mask but no eye protection. R1 was rolled to his side and the dressing on his buttock was removed. R1 had a golf ball size wound on his sacrum, a dime size wound on the right buttock, and a pea size wound on the left buttock. V3 sprayed wound cleanser onto a cotton gauze pad and randomly blotted all three open areas. V3 used the same gauze pad on the three wounds and went back and forth over the areas. V3 and V5 completed the treatment, exited the room, and left the door open. V3 was questioned about the isolation sign on the door and the required PPE. V3 said she thought R1 was past the required number of days needed for droplet precautions and really is only on enhanced barrier precautions due to his buttocks wounds. V3 said gowns and gloves are all that are needed now and only when doing direct care. On 2/6/25 at 11:20 AM, V2 (DON-Director of Nurses) stated R1 is still on droplet precautions due to the MRSA in his sputum. R1 needs to stay on isolation until the completion of the antibiotics. A one week wait period is required and a negative sputum culture is needed before he can come off droplet isolation. V2 said R1 will be retested on [DATE]. On 2/6/25 at 1:20 PM, V2 (DON) stated the sign posted outside R1's room is wrong. It does not show the correct PPE required and is not stringent enough. The sign should show that gowns, gloves, N95 masks, and face shields are required anytime staff enter. V2 said there is a high risk for cross Page 1 of 2 145989 145989 02/06/2025 Parker Nursing & Rehab Center 516 West Frech Street Streator, IL 61364

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few contamination between residents if staff are not wearing the right PPE. V2 supplied a second droplet precaution sign and said this is the one that should have been posted. The sign showed full PPE was required prior to entering the room. On 2/6/25 at 12:05 PM, V3 (WCN/ICP) stated the correct way to cleanse wounds is with a fresh cotton gauze for each sore. Sharing the same gauze pad can cross contaminate the wounds. V3 stated wounds should be wiped in an inward to outward manner. Random blotting can bring germs from the outer edges into the wound bed. On 2/6/25 at 2:45 PM, V7 (Wound Physician) stated wounds should be cleansed individually with fresh pads for each one. The areas need to be wiped from the inner to outer areas. It helps to reduce the risk of infection. The facility's undated Wound Cleansing and Dressings policy states under the procedure section: B. Cleanse starting with the cleaner appearing wounds and move to larger and more contaminated wounds. The facility's undated Guidelines for Prevention/Treatment of Pressure Injuries policy states under the treatment section: A clean field, using clean instruments and prevention of direct contamination of materials and supplies are also required. The facility's undated Infection Control/Isolation Guidelines policy states: A. Isolation precautions shall remain in effect until the condition is ruled out or the criteria for duration have been met. 145989 Page 2 of 2