Health inspection·September 12, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation, interview, and record review the facility failed to ensure a multi-dose vial was labeled when opened and failed to ensure controlled medications were double locked. This has the potential to affect all residents in the facility. The findings include: The CMS 671 form dated 9/10/24 showed six residents reside in the certified unit of the facility. 1. On 9/12/24 at 9:05 AM, the facility medication room was reviewed. The unit refrigerator had an opened vial of multi-dose tuberculin (TB) solution inside, and it was approximately half dispensed. The vial was not dated or labeled with an open or expiration day. V9 (Registered Nurse) was present and verified the vial was half used and there was no labeling. On 9/12/24 at 10:52 AM, V2 (Director of Nurses) stated the vial should have been dated when it was opened. It should show the date, time, and initials of the nurse that opened it. The information is important to ensure the solution is not used past the expiration day. There is no way of knowing if it is still effective if the date it was opened is missing. The facility's Maintenance of Medication Inventory policy last review dated 8/23 states: Opened multi-dose bottle such as TB solution should have a date opened sticker, if expires in 24 hours or less order replacement (expires in 30 days after opened). 2. R3's face sheet printed on 9/12/24 showed an admission date of 8/6/24. R3's physician order report showed an order start dated 9/2/24 for alprazolam (anxiety medication) at 0.25 milligrams every 24 hours as needed for sleeplessness. The same report showed an order start dated 8/7/24 for pregabalin (convulsion medication) at 50 milligrams two times a day for anticonvulsant. R57's face sheet printed on 9/12/24 showed and admission date of 8/31/24. R57's physician order report showed an order start dated 9/1/24 for pregabalin at 100 milligrams three times a day for anticonvulsant. On 9/12/24 at 9:05 AM, the facility medication cart was reviewed. The bottom drawer of the cart contained the narcotics box, and the lid was unlocked. R3's alprazolam and pregabalin medication cards where in the box. R57's pregabalin medication cards were in the box. V9 (Registered Nurse) stated the lid tends to catch on the top of the medication cards and block it from locking. It happens a lot. It should not be unlocked like that. Page 1 of 5 146105 146105 09/12/2024 Oak Crest 2944 Greenwood Acres Drive Dekalb, IL 60115

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 9/12/24 at 10:52 AM, V2 (Director of Nurses) stated narcotics need to be under a double lock system at all times. They have a high risk of misuse and need extra close monitoring. V2 said staff need to be checking the lock even more closely knowing the medication cards cause an issue with it locking correctly. The facility's Medication Administration policy last review dated 8/23 states: 8. Medication room/Narc box/tx (treatment) cupboard is never left unlocked when unattended and the medication room/cart/cupboard key will be in the possession of authorized personnel at all times. 146105 Page 2 of 5 146105 09/12/2024 Oak Crest 2944 Greenwood Acres Drive Dekalb, IL 60115

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 store frozen items off the floor. This failure has the potential to affect all residents in the facility. Residents Affected - Many The findings include: The CMS 671 dated 9/10/24 showed 6 residents reside in certified beds. On 9/11/24 at 11:15 AM and 12:30 PM (One hour and fifteen minutes) a box of lemon and cream cakes was stored on the floor of the walk-in freezer. On 9/11/24 at 11:15 AM, V7 Kitchen Manager stated the facility did not receive a food delivery that day. On 9/11/24 at 12:43 PM, V7 stated the lemon cake was the desert for dinner that evening. V7 stated food should not be stored on the floor; it should be on a shelf. On 9/11/24 at 12:45 PM, V8 Director of Food and Nutrition stated the lemon shortcake was only stored on the floor momentarily. V8 stated food should be stored six inches off the floor. V8 stated, the purpose of storing food off the floor is to prevent pests from getting into food and floor chemicals getting on food. V8 stated, storing food off the floor also allows proper airflow around food to prevent spoilage. V8 stated, she would consider momentary to be five minutes. The facility Storage of Frozen Foods policy (Revision 2017) showed, .Appropriate storage procedures are followed: First-in-first-out. Food is stored six inches above the floor. Food is stored to allow air circulation . 146105 Page 3 of 5 146105 09/12/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R 57's admission record shows he was admitted to the facility on [DATE]. His order summary report for September 12, 2024, documents admission orders for indwelling catheter care. Residents Affected - Many The 8/31/24 care plan for R57 shows him to be placed on EBP (Enhanced Barrier Precautions) due to having an indwelling urinary catheter and wounds. On 9/10/24, R57's room and doorway were found to have no signs indicating EBP, or gowns available for staff to enter his room. On 9/11/24 at 9:55 AM, V5 CNA (Certified Nursing Assistant) was observed performing catheter care, and placing the leg drainage bag around R57's leg. She was not wearing any gown. After placing the leg bag, she assisted R57 to get dressed, then placed a gait belt around him and ambulated him to the recliner. On 9/11/24 at 1:04 PM, V2 DON (Director of Nursing) stated EBP is an added layer of protection for residents who have a heightened risk of infection. It is put in place for residents with chronic wounds, PICC lines (peripheral inserted central catheter), and indwelling catheters to prevent the spread of infection. EBP is required for those residents, it is not an option. Placing residents in EBP is the responsibility of the nurses on the floor and then I would be a backup when I do my 24 hour charting review. On 9/11/24 at 2:02 PM, V4 LPN (Licensed Practical Nurse) said EBP should be in place for residents with open wounds and indwelling catheters. V4 said she does realize she messed up and R57 should be on EBP due to his open wounds and catheter. She said staff should be wearing a gown and gloves when providing care and dressing changes. The facility's 5/24 policy for Enhanced Barrier Precautions documents it to be an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing home. EBP involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (for example: residents with wounds or indwelling medical devices). Staff should perform hand hygiene before entering the resident's room and applying gown/gloves and immediately upon removal. Based on interview and record review the facility failed to have a Legionella (bacteria) prevention and mitigation program in place. The facility also failed to implement enhanced barrier protections (EBP) for a resident with an indwelling catheter. These failures have the potential to affect all residents in the facility. The findings include: The CMS 671 dated 9/10/22 showed 6 residents reside in certified beds. 1. On 9/11/24 at 1:04 PM, V2 Director of Nursing stated V6 Facility Director was responsible for the Legionella program (a bacteria that can cause pneumonia). The facility's Legionella policies for prevention and mitigation were requested from V2. 146105 Page 4 of 5 146105 09/12/2024 Oak Crest 2944 Greenwood Acres Drive Dekalb, IL 60115

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 9/11/24 at 2:09 PM, V6 stated he has been the maintenance director for 8 months. V6 stated he does not have a legionella mitigation and prevention program for the facility. On 9/12/24 at 8:55 AM, V2 stated Legionella bacteria live in the water in pipes with little to no flow. V2 said the elderly are more susceptible to Legionnaires infection. V2 was uncertain regarding the consequences of a resident contracting Legionella. The Centers for Disease Control (CDC) website About Legionnaires; Disease (dated 1/29/24) showed, Legionnaires' disease is a serious type of pneumonia caused by Legionella bacteria. Certain people are at increased risk for the infection, but it's treatable with antibiotics. People can get Legionnaires' disease by breathing in mist containing Legionella bacteria. To prevent Legionnaires' disease, reduce the risk of Legionella growth and spread . The CDC website How Legionella Spreads (dated 1/29/24) showed .People at increased risk of getting sick include: Current or former smokers. People 50 years or older . 146105 Page 5 of 5