Health inspection·August 15, 2023

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 interview and record review the facility failed to have a PRN (as needed) psychotropic medication stop date to 1 of 5 residents (R59) reviewed for unnecessary medications in the sample of 5. The findings include: R59's Physician Order Sheet (POS) dated 8/2023 show, R59 has an order of: start date- 8/10/23 Risperdal Oral Tablet 0.25 MG (Risperidone) Give 0.25 mg by mouth every 12 hours as needed (PRN) for agitation and insomnia. On 8/15/23 at 9:15 AM, V2 (Director of Nursing-DON) said all psychotropic as needed medications should have a 14 day stop date unless the physician renews the PRN meds. V2 said we will be working on this and ensure all PRN psychotropic medications have a 14 day stop date. The facility policy on Psychotropic Medications with a review date of 8/2023 show, all PRN psychotropic medications will have an automatic stop date of 14 days unless specified by the medical provider. Page 1 of 3 146105 146105 08/15/2023 Oak Crest 2944 Greenwood Acres Drive Dekalb, IL 60115

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 wash hands after providing pericare to prevent the spread of infection to 1 of 5 residents (R58) reviewed for infection control in the sample of 5. Residents Affected - Few The findings include: On 8/14/23 at 9:10 AM, V4 (Certified Nursing Assistant-CNA) toileted R58 and provided peri care after R58 had a bowel movement. V4 (CNA) then removed her soiled gloves but did not wash hands/did not perform hand hygiene. Using her contaminated hands V4 took R58's toothbrush, applied tooth paste then handed the toothbrush to R58 and gave R58 a cup of water. V4 then wheeled R58 and assisted R58 to his recliner all doing these tasks without washing her hands. On 8/15/23 at 8:50 AM, V5 (Registered Nurse) said staff should wash their hands prior to and after giving care. V5 also said every time staff remove their gloves, they should perform hand hygiene to prevent the spread of infection, The facility Policy entitled Hand Hygiene with a revised date of 4/2020 show, it is the policy of this organization to promote use of alcohol sanitizers and handwashing as the single most important means of preventing the spread of infection. Examples of situation when hand hygiene is indicated before and after direct resident contact (care, treatment). 146105 Page 2 of 3 146105 08/15/2023 Oak Crest 2944 Greenwood Acres Drive Dekalb, IL 60115

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer the pneumococcal conjugate vaccines (PCV20) or the pneumococcal polysaccharide vaccine (PPSV23) for 1 of 5 residents (R58) reviewed for vaccinations in the sample of 5. Residents Affected - Few The findings include: R58's face sheet shows he is an [AGE] year-old male admitted to the facility on [DATE] with diagnosis including pneumonitis due to inhalation of food and vomit, atrial fibrillation, hypertension, and presence of cardiac pacemaker. R58's Immunization Report provided on 8/14/23 shows on 10/9/2015 he received Prevnar 13 (PCV13). There were no other pneumococcal vaccinations recorded. On 8/15/23 at 12:03 PM, V3 Assistant Director of Nursing (ADON) said R58 received Prevnar 13 in 2015, he is eligible to receive the 2nd dose of the pneumococcal vaccine. It should've been offered on admission and given if consented. Residents should receive the 2nd dose of the pneumococcal vaccine after one year of receiving PCV13. The CDC (Centers for Disease Control and Prevention) guidelines dated February 2013 shows states, the CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information .For adults 65 years or older who have only received PCV13, CDC recommends you either: Give 1 dose of PCV20 at least 1 year after PCV13 or Give 1 dose of PPSV23 at least 1 year after PCV13 . The facility's Flu and Pneumonia Vaccines revised 2018, states, All residents living in licensed units will be offered an annual flu vaccine in accordance with the recommendations of the Advisory Committee of the Centers for Disease Control and with the approval of their physician and the resident's consent, (if resident unable to make decision, legally responsible party will be consulted), unless they have had previous reactions to the vaccine, are allergic to eggs, have a history of Guillain Barre Syndrome, or are ill .All residents age [AGE] and older living in a licensed unit will be offered a pneumonia vaccine in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control upon admission and with the approval of their physician, and with the resident's consent .Administration of, refusal of, or medical contraindication of a pneumonia vaccine will be documented in the resident's medical record. 146105 Page 3 of 3