Health inspection·May 24, 2023

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. 3. On May 22, 2023, at 12:37 PM, R9 was seated in the dining room. V5 CNA was standing next to R9 while she was feeding him soup and his main meal. Residents Affected - Few 4. On May 23, 2023, at 12:10 PM, V9 CNA was on her cell phone in the dining room while feeding R11. At 12:25 PM, V9's cell phone was sitting next to her on top of the table while she was still feeding R11. On May 23, 2023, at 8:24 AM, V3 Registered Nurse stated, Staff are not to be standing when feeding residents. Staff are to be face-to-face with residents. It's a dignity issue. Per our policy, staff are not to be standing. On May 23, 2023, at 1:50 PM, V8 CNA said staff should be sitting down while feeding residents so that they are able to face the residents and see eye to eye. V8 said cell phones should not be used while feeding residents. The facility's Assistance with Meals policy dated December 6, 2022, shows, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals. Based on observation, interview and record review the facility failed to ensure residents were treated in a dignified manner during dining for three of 11 residents (R11, R3, R9) reviewed for dignity in the sample of 11. The findings include: 1. On May 22, 2023, at 12:16 PM, R11 was seated in the dining room. V5 Certified Nursing Assistant (CNA) stood next to R11, feeding R11 soup. 2. On May 22, 2023, at 12:20 PM, R3 was seated in the dining room. V7 CNA stood next to R3, feeding R3 soup. Page 1 of 9 146118 146118 05/24/2023 Prairieview at the Garlands 6000 Garlands Lane Barrington, IL 60010

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** 3. R9's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, and hematuria. Residents Affected - Some R9's MDS (Minimum Data Set) dated March 2, 2023, shows he requires total assistance with toilet use, personal hygiene, bed mobility, and transferring. R9 is always incontinent of bowel and bladder. R9's Care Plan shows he has an ADL (Activities of Daily Living) self care performance deficit related to Alzheimer's, dementia. R9 is dependent on staff for repositioning, turning in bed, personal hygiene and oral care. On May 22,2023, R9 was observed sitting in a tall back recliner at various times from 9:30 AM-1:13 PM. On May 22, 2023, at 1:13 PM, V4 and V5 CNA (Certified Nursing Assistant) transferred R9 from the recliner to the bed. There was urine and stool in R9's incontinence brief. There were creases on R9's buttocks from sitting in the recliner. V4 said that R9 has been up in the recliner since 6:30 AM. 4. R8's Face Sheet shows she was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease and history of falling. R8's MDS dated [DATE] shows she requires extensive assistance with bed mobility and transferring. R8 requires total assistance for toilet use and personal hygiene. R9's Care Plan shows she has bladder incontinence related to activity intolerance, confusion, dementia, urinary tract infection, and impaired mobility. Clean peri-area with each incontinence episode. On May 22, 2023, R9 was observed sitting in her high back recliner at various times from 9:29 AM-12:55 PM. At 12:55 PM, V4 and V5 transferred R9 into bed. R9's incontinence brief was saturated with urine and creases were noted to R9's skin on her upper legs and buttocks. There was stool noted to R9's buttocks. V4 said that R9 has been up and in her high back recliner since about 7:30 AM. On May 23, 2023, at 1:50 PM, V8 CNA said incontinence care and repositioning should be done at lease every two hours in order to protect residents skin. The facility's Activities of Daily Living policy dated December 6, 2022, shows, Residents will be provided with care, treatment and services as appropriated to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The facility's Perineal Care Policy dated December 6, 2022, shows, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Based on observation, interview and record review the facility failed to provide ADL (activities of daily living) assistance for residents' requiring assistance for incontinence care for 4 of 11 residents (R11, R3, R9, R8) reviewed for ADLs in the sample of 11. 146118 Page 2 of 9 146118 05/24/2023 Prairieview at the Garlands 6000 Garlands Lane Barrington, IL 60010

F 0677 The findings include: Level of Harm - Minimal harm or potential for actual harm 1. R11's admission Record form showed R11 was admitted to the facility on [DATE], with diagnoses including altered mental status, dementia, and Alzheimer's disease. Residents Affected - Some R11's resident assessment dated [DATE], showed R11 required the extensive assistance of staff for toileting and repositioning. The assessment showed R11 was incontinent of bowel and bladder. On May 22, 2023, at 9:26 AM, R11 was asleep, seated in a recliner in a room. An odor of stool was noted in R11's room. On May 22, 2023, at 10:31 AM, R11 remained asleep in the recliner in her room. An odor of stool remained in R11's room. On May 22, 2023, at 11:13 AM, R11 remained asleep in the recliner in her room. An odor of stool remained in R11's room. On May 22, 2023, at 11:50 AM, V4 Certified Nursing Assistant (CNA) and V5 CNA entered R11's room to provide cares. V4 and V5 assisted R11 out of her wheelchair, to the toilet, via a mechanical lift. As R11 stood in front of the toilet, V5 CNA began removing R11's brief. As V5 removed the brief, a large amount of mushy, liquid stool, fell out of the brief onto the floor, Stool was noted leaking out of the brief, onto R11's inner thighs. R11's entire buttock area was covered with a large amount of stool. R11's buttocks were reddened. V5 CNA stated, We got (R11) up around 7:30 AM this morning. We did incontinence care at that time (4.5 hours prior). 2. R3's current care plan showed R3 was cognitively impaired with diagnoses of dementia, aphasia, and intracerebral (brain) hemorrhage. R3's resident assessment dated [DATE], showed R3 was totally dependent on staff for cares/ADLs. The assessment showed R3 was incontinent of bowel and bladder. On May 22, 2023, at 9:35 AM, R3 was seated in a wheelchair in the activity room. A mechanical lift, cloth sling was noted underneath R3 in the wheelchair. On May 22, 2023, at 10:30 AM, R3's family wheeled R3 out of the activity room, down to her room for a visit. On May 22, 2023, at 11:05 AM, R3's family wheeled R3 into the dining room, where facility staff were seated. On May 22, 2023, at 12:13 PM, R3 remained in the dining room as facility staff fed her lunch. On May 22, 2023, at 1:15 PM, R3 remained in the dining room, asleep in her wheelchair. On May 22, 2023, at 2:00 PM, V4 and V5 CNAs wheeled R3 into her room to provide cares. R3 was transferred to her bed by V4 and V5 CNAs. V4 removed R3's incontinence brief. R3's brief was saturated with urine and a small amount of stool. R3's buttocks were reddened with visible creases indented in the skin of her buttocks from the mechanical lift cloth sling R3 was sitting on. V4 CNA stated, I got (R3) up around 6:30 AM this morning and did incontinence then (7.5 hours prior). She was the first 146118 Page 3 of 9 146118 05/24/2023 Prairieview at the Garlands 6000 Garlands Lane Barrington, IL 60010

F 0677 one I got up. I haven't done incontinence care on her since then. Level of Harm - Minimal harm or potential for actual harm On May 23, 2023, at 8:24 AM, V3 Registered Nurse stated, Residents should be repositioned every 2 hours. Residents should be checked for incontinence every 2 hours and cleaned up when needed. Residents Affected - Some 146118 Page 4 of 9 146118 05/24/2023 Prairieview at the Garlands 6000 Garlands Lane Barrington, IL 60010

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** 3. R9's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, hematuria, and dementia. Residents Affected - Few R9's MDS (Minimum Data Set) dated March 2, 2023, shows R9 requires total assistance with bed mobility and transferring. R9's Scale for Predicting Pressure Injury Risk dated May 23, 2023, shows R9 is high risk for developing pressure injuries. R9 Order Summary Report dated May 23.2023 shows an order for low air loss mattress dated June 18,2021. R9's Care Plan shows R9 has a potential for pressure injury development related to history of skin breakdown and limited mobility. R9 has a history of pressure injuries to his buttock. Intervention for low air loss. On May 22, 2023, at 1:13 PM, R9 was transferred into his bed. R9 had an air mattress pump to the foot of his bed and the pump was shut off. On May 23, 2023, at 2:03 PM, the mattress pump was shut off again. V4 CNA stated she thought the air mattress (pump) was on. Based on observation, interview and record review the facility failed to ensure pressure injury treatments and interventions were in place for 3 of 3 (R11, R2, R9) residents reviewed for pressure injuries in the sample of 11. The findings include: 1.R11's admission Record form showed R11 was admitted to the facility on [DATE], with diagnoses including altered mental status, dementia, and Alzheimer's disease. R11's Skin/Wound note dated March 22, 2023, showed a new open wound was found to R11's sacral/coccyx area, measuring 3.0 cm (centimeters) x 0.3 cm. R11's Skin/Wound note dated May 22, 2023, showed, Skin remains fragile. Coccyx area remains with superficial open area, (Stage) 2. R11's current care plan showed, Keep skin clean and dry .Follow facility protocols for treatment of injury .Cleanse open area to sacrum, pat dry, apply Mepilex (foam) dressing, change dressing every 3 days and prn (as needed) until healed. On May 22, 2023, at 9:26 AM, R11 was asleep, seated in a recliner in a room. An odor of stool was noted in R11's room. On May 22, 2023, at 10:31 AM, R11 remained asleep in the recliner in her room. An odor of stool remained in R11's room. On May 22, 2023, at 11:13 AM, R11 remained asleep in the recliner in her room. An odor of stool 146118 Page 5 of 9 146118 05/24/2023 Prairieview at the Garlands 6000 Garlands Lane Barrington, IL 60010

F 0686 remained in R11's room. Level of Harm - Minimal harm or potential for actual harm On May 22, 2023, at 11:50 AM, V4 Certified Nursing Assistant (CNA) and V5 CNA entered R11's room to provide cares. V4 and V5 assisted R11 out of her wheelchair, to the toilet, via a mechanical lift. As R11 stood in front of the toilet, V5 CNA began removing R11's brief. As V5 removed the brief, a large amount of mushy, liquid stool, fell out of the brief onto the floor, Stool was noted leaking out of the brief, onto R11's inner thighs. R11's entire buttock area was covered with a large amount of stool. No dressing was noted to the circular reddened area to R11's coccyx area. No dressing was noted in R11's soiled incontinence brief. R11's buttocks were reddened. V5 CNA stated, We got (R11) up around 7:30 AM this morning. We did incontinence care at that time (4.5 hours prior). She doesn't have a dressing to her bottom. She doesn't need one. Residents Affected - Few On May 23, 2023, at 8:24 AM, V3 Registered Nurse (RN) stated, (R11) has a stage 2 (pressure injury) to her coccyx .She is to have a foam dressing over her coccyx wound. It gets changed every 3 days and as needed. If the dressing is missing or has fallen off, staff are to tell the nurse so we can apply a new one. To help her wound heal, she is on a low air loss mattress, has a dressing to her coccyx, reposition her every 2 hours, and make sure her skin is kept clean and dry. No one told me yesterday that (R11) did not have a dressing over her coccyx wound. 2.R2's Wound Progress Note dated May 10, 2023, showed R2 had an unstageable pressure injury to her left heel and a stage 2 pressure injury to her right heel. R2's left heel pressure injury measured 3.5 cm x 4 cm x 0.4 cm. R2's right heel pressure injury measured 0.7 cm x 0.4 cm x 0.2 cm. R2's physician progress note dated May 1, 2023, showed, Needs offloading boots on at all times. On May 22, 2023, at 9:36 AM, R2 was seated in a wheelchair in her room. Gauze dressings were noted to both of R2's heels. No offloading boots were noted to R2's feet. On May 22, 2023, at 10:05 AM, R2 remained seated in a wheelchair in her room. No offloading boots were noted to R2's feet. The facility's Prevention of Pressure Injuries policy dated December 6, 2022, showed, Clean promptly after episodes of incontinence. Use facility-approved protective dressings for at risk individuals, Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. 146118 Page 6 of 9 146118 05/24/2023 Prairieview at the Garlands 6000 Garlands Lane Barrington, IL 60010

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure peri care was provided in a manner to prevent urinary tract infections and failed to maintain a urinary drainage bag below the level of the bladder for two of five residents (R9, R15) reviewed for incontinence care and catheter care in the sample of 11. The findings include: 1. R9's admission Record shows he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hematuria, and dementia. R9's MDS (Minimum Data Set) dated March 2, 2023, shows he is always incontinent of bowel and bladder. R9's Care Plan shows he is totally dependent on staff for personal hygiene and oral care. On May 22, 2023, at 1:13 PM, V4 and V5 CNAs (Certified Nursing Assistants) transferred R9 from his recliner to his bed. R9 had urine and stool in his incontinence brief. V5 CNA wiped the stool from R9's buttocks but did not clean the urine from R9's front peri area. On May 23, 2023, at 1:50 PM, V8 CNA said residents peri areas should be washed from front to back. The facility's Perineal Care policy dated December 6, 2022, shows, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Wash perineal area starting with urethra and working outward .continue to wipe the perineal area including the penis, scrotum and inner thighs. Wash and rinse the rectal area thoroughly. 2. R15's admission Record shows he was admitted to the facility on [DATE], with diagnoses including urinary retention, gross hematuria, cognitive communication deficit, and acute kidney failure. R15's Care Plan dated April 25, 2023, shows R15 has a urinary catheter and to position catheter bag and tubing below the level of the bladder and away from entrance room door. On May 22, 2023, at 1:24 PM, V4 and V5 CNAs transferred R15 from his wheelchair to the toilet. V5 lifted R15's urinary drainage bag above the level of his bladder while he was sitting in the wheelchair. There was urine in R15's urinary drainage bag and in the tubing of the urinary catheter. On May 23, 2023, at 1:50 PM, V8 CNA said the urinary drainage bag should be kept below the level of the resident's bladder, so urine doesn't flow back and cause infection. The facility's Indwelling Catheter Protocol dated October 24, 2018, shows, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. 146118 Page 7 of 9 146118 05/24/2023 Prairieview at the Garlands 6000 Garlands Lane Barrington, IL 60010

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. R67's admission Record shows he was admitted to the facility on [DATE], with diagnoses including sepsis and urinary tract infections. Residents Affected - Many On May 22, 2023, at 10:10 AM, V4 and V5 CNAs (Certified Nursing Assistants) transferred R67 from his wheelchair to his bed. There was a large amount of stool noted to the back of R67's pants. V5 removed R67's soiled pants and folded the soiled brief down in between R67's legs. V5 then touched R67's knees and the safe transfer belt. V4 wiped R67's front peri area then touched R67's body to help him to turn to his side. V5 then wiped R67's buttocks, there was stool noted to V5's right pointer finger glove. V5 then touched the wipes container and R67's call light. There was no glove change or hand hygiene performed by V4 or V5. 3. R8's admission Record shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and history of falling. R8's MDS (Minimum Data Set) dated March 20, 2023, shows R8 is frequently incontinent of urine and always incontinent of stool. On May 22, 2023, at 12:55 PM, V5 CNA folded R8's incontinence brief down, in between her legs. V5 wiped R8's front peri area, then turned R8 onto her side in order to wipe R8's buttocks. V5 did not change her gloves or perform hand hygiene. 4. R13's MDS dated [DATE], shows he is always incontinent of bowel and bladder. On May 22, 2023, at 10:51 AM, V4 and V5 placed R13 onto the toilet. There was stool noted in R13's incontinence brief. V5 removed the soiled incontinence brief and placed a new brief around R13's legs. V5 then touched R13 to help him to stand. V4 wiped the stool from R13's buttocks, then pulled the new clean incontinence brief up, touched R13's body, and touched R13's wheelchair. There was no glove change or hand hygiene performed by V4 or V5. On May 23, 2023, at 1:50 PM, V8 CNA said gloves should be changed before you touch clean items. The facility's Handwashing/Hand Hygiene policy dated December 6, 2022, shows, This facility consider hand hygiene the primary means to prevent the spread of infections. Use an alcohol based hand rub; or alternatively, soap and water for the following situations: before and after direct contact with residents, before and after handling an invasive device, and before handling clean or soiled dressings. Before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin. Based on observation interview, interview, and record review the facility failed to ensure enhanced barrier precautions were implemented and failed to change gloves and perform hand hygiene during incontinence care in a manner to prevent cross contamination. This has the potential to affect all 15 residents residing in the facility. The findings include: 1. The facility's Resident Census and Condition Report (CMS 672) dated May 22, 2023, shows a 146118 Page 8 of 9 146118 05/24/2023 Prairieview at the Garlands 6000 Garlands Lane Barrington, IL 60010

F 0880 resident census of 15. Level of Harm - Minimal harm or potential for actual harm On May 23,2023 at 09:16 AM, V2 Director of Nursing (DON) said the facility has no residents on transmission based precautions (TBP) or enhanced barrier precautions (EBP). V2 said there is no specific facility policy on enhanced barrier precautions. Residents Affected - Many The facility's Matrix dated May 22, 2023 shows R12, R14, and R15 have urinary indwelling catheters and R2 and R11 have pressure wounds. On May 23.2023 at 01:40 PM, V2 said the facility has not updated their transmission based precautions to include enhanced barrier precautions. V1 Administrator said they recall hearing about EBP but have not implemented the precautions at the facility. V2 said EBP would apply to residents with urinary catheters or wounds. V2 said the facility has 5 residents that have catheters and/or wounds. V2 said staff should wear gown and gloves when providing care for residents on EBP. The CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated July 12, 2022, shows: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and/or Infection or colonization with an MDRO. 146118 Page 9 of 9