Health inspection·December 10, 2024

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** Based on observation, interview, and record review, the facility failed to ensure residents were changed in a timely manner for 1 of 9 residents (R3) reviewed for Activities of Daily Living (ADL) in the sample of 9. Residents Affected - Few The findings include: On 12/9/24 at 9:43 AM, R3's call light was alarming. R3 said she needs her wet diaper changed and has been wet all morning. R3 said she was last changed in the early morning around 6:00 AM to 7:00 AM. R3 said her call light was answered once and staff said they would be back to change her, but that was over an hour ago and no one has returned. R3 said she feels very wet and staff never check on her. During this conversation, V6 (Licensed Practical Nurse/LPN) came in and said she would return to change her. On 12/9/24 at 9:53 AM, R3 pushed her call light again and at 9:56 AM, someone said, over the intercom, they would be in to change her. V7 (Certified Nursing Assistant/CNA) arrived to change R3 at 9:58 AM. When V7 removed R3's brief, the brief, the disposable pad, and the cloth draw sheet were all soaked with urine. R3's buttocks were red and excoriated. On 12/9/24 at 10:05 AM, V7 (CNA) said she checks on the residents every hour, and changes incontinent residents three times a day, but they are short staffed on CNAs today. On 12/9/24 at 1:33 PM, V2 (Director of Nursing) said incontinence briefs need to be changed when the resident calls to be changed. On 12/10/24 at 9:31 AM, V9 (CNA) said residents need to be changed as soon as possible when they are wet. R3's admission Record dated 12/10/24 shows R3 is an [AGE] year-old female and her diagnoses include, but are not limited to, need for assistance with personal care and lack of coordination. R3's current care plan provided by the facility shows R3 has ADL self-care performance deficits and limitations in physical mobility. R3 requires substantial/maximal assistance with toileting hygiene. R3 is at risk for alteration in skin integrity and has actual impairment of moisture associated skin damage (MASD) to her sacral area and her skin is to be kept clean and dry. The facility's ADLs Policy (dated 5/2018) shows the facility is to ensure resident activities of daily living are being adequately met. Page 1 of 2 146143 146143 12/10/2024 Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133

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 implement and/or follow Enhanced Barrier Precautions (EBP) for 3 of 3 residents (R1, R2, R3) reviewed for infection control in the sample of 9. Residents Affected - Few The findings include: On 12/9/24 at 9:22 AM, R2 was sitting on his bed in his room. R2 said he had his toes amputated and they got infected. There was no sign on R2's door, there was no PPE (personal protective equipment) outside of R2's room. On 12/9/24 at 9:43 AM, R3 was lying in bed in her room. R3 said staff do not wear gowns when providing care; I'm not contagious. R3's left lower leg had a long row of staples along a surgical incision. On 12/9/24 at 9:58 AM, V7 (Certified Nursing Assistant/CNA) arrived to R3's room to change her brief. V7 did not wear a gown when she changed R3's brief. On 12/9/24 at 10:10 AM, R1 was lying in his bed watching TV. A dressing/bandage was noted to R1's left lower leg with a small amount of drainage on it. There was no sign on R1's door, there was no PPE outside of R1's room. On 12/9/24 at 10:39 AM, V3 (Infection Prevention Nurse/Assistant Director of Nursing) said staff are required to wear a gown and gloves when providing ADL (activities of daily living) care, such as changing the resident's brief, to residents on EBP. V3 said residents with open wounds, an indwelling urinary catheter, central lines, g-tubes, or any external device entering their body are required to be placed on EBP right away. V3 said he gets an order for EBP, notifies the patient and family, and places signs on the resident's door to indicate their isolation needs. V3 said a drawer of PPE is placed outside of the given room. V3 said staff know if a resident is on isolation, such as EBP, and what PPE is required by the sign on the door. R1's Order Summary Report dated 12/10/24 shows an order on 12/2/24 for Enhanced Barrier Precautions (EBP) due to wounds. R2's admission Record dated 12/10/24 shows he was admitted to the facility on [DATE]. R2's Order Summary Report dated 12/10/24 shows an order on 12/9/24 for Enhanced Barrier Precautions (EBP) due to surgical wounds. R3's Order Summary Report dated 12/10/24 shows an order on 12/4/24 for Enhanced Barrier Precautions (EBP) due to wounds. The facility's Enhanced Barrier Precautions List (undated) provided by the facility on 12/9/24 includes R1, R2, and R3. The facility's Enhanced Barrier Precautions Policy dated March 2024, shows EBP refers to an infection control intervention that employs gown and glove use during high contact resident care activities, including changing briefs or assisting with toileting. Residents with wounds require EBP for all cares and services. 146143 Page 2 of 2