Health inspection·December 7, 2023

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. R41 had multiple diagnoses including senile degeneration of brain and dementia without behavioral disturbances, based on the face sheet. Residents Affected - Some R41's quarterly MDS (minimum data set) dated August 29, 2023 showed that the resident was cognitively intact. The same MDS showed that R41 required extensive assistance from the staff with regards to personal hygiene. On December 4, 2023 at 9:53 AM, R41 was sitting in her wheelchair in front of the unit nursing station. R41 was alert and verbally responsive. R41's fingernails were long, jagged and with black/brown substances underneath several of her fingernails. R41 stated, My nails are too long, but I do not have the energy to cut them. R41 requested to have her nails trimmed and cleaned. V8 (Licensed Practical Nurse) was at the nursing station during this observation and interview. R41's active care plan initiated on October 27, 2020 showed that the resident had ADL (activities of daily living) self-care performance deficit. The same care plan showed multiple interventions including, Assist with personal hygiene as needed and Provide needed level of assistance and support to complete activities of daily living. Based on observation, interview, and record review, the facility failed to provide timely hygiene and grooming care for residents who requires assistance for activities of daily living (ADL) care. This applies to 4 of 4 residents (R5, R11, R41, R230) reviewed for ADL care in the sample of 19. The findings include: 1. R11 is 88 years-old who has multiple medical diagnoses which include dementia, polyarthritis, and chronic pain. R11's Quarterly Minimum Data Set (MDS) dated [DATE], shows that R11 is alert and oriented and requires assistance with ADL care. On December 4, 2023, at 11:45 AM, R11 was sitting in her wheelchair, and neatly dressed. However, R11 displayed overgrown facial hair all over the chin. R11 stated that she wants to be shaven. On December 6, 2023, at 12:10 PM, R11 was eating in the dining room, she remained with overgrown facial hair. R11 still wanted to have her facial hair shaven. V16 (Wound Care Technician/Certified Nursing Assistant) stated that shaving is part of ADL care. 2. R5 is 73 years-old who has multiple medical diagnoses which include stage 4 pressure ulcer of the right buttock, multiple sclerosis, type 2 diabetes mellitus, diaper dermatitis, contracture of Page 1 of 11 146153 146153 12/07/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some muscle right lower leg, incontinence without sensory awareness. R5's Annual MDS dated [DATE], shows that R5 is alert and oriented and totally dependent with toileting and personal hygiene. On December 5, 2023, at 11:27 AM, R5 was lying in bed, with indwelling urinary catheter. V5 (Wound Care Technician) and V6 (Wound Nurse) were about to render wound care to R5 when they turned R5 on the left side and it showed that R5 was heavily wet with urine. R5's incontinence brief was heavily saturated with dark brown urine which overflowed to her bed linen and to the mattress. The wound dressing was also wet with urine and there was a strong urine odor. The bed linen that was also wet with dark brown urine had thick line formation of brown ring stain at the edges of the wetness. Apparently, her urinary catheter leaked. R5 stated they (staff) checked her early that morning. On December 5, 2023, at 12:01 PM, V17 (Certified Nursing Assistant/CNA) and V5 (Wound Care Technician) rendered sponge bath to R5. V17 stated that the last time they checked and changed R5's brief was around 7:00 AM. On 12/06/23 at 10:11 AM, V2 (Director of Director/DON) stated that staff should check and change residents for incontinence every 2 hours and as needed. The staff can't let a resident sit in urine and feces for a long period of time. This is for the prevention of skin breakdown, to provide hygiene, and dignity. R5' care plan, which was initiated on October 29, 2022, and had a target goal of March 1, 2024, shows that R5 has an actual alteration in skin integrity related to pressure injury to her right buttock. The same care plan shows multiple interventions which include to keep R5's skin clean and dry, and peri-care after incontinent episodes. 4. R230's EMR (Electronic Medical Record) showed R230 was admitted to the facility on [DATE], with diagnoses that included fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing, polyneuropathy, peripheral vascular disease, overactive bladder, and restless leg syndrome. R230's admission MDS (Minimum Data Set) dated December 1, 2023, showed R230 was cognitively intact. R230's functional abilities on admission showed she was dependent on staff for toileting, shower/bath, upper body dressing, lower body dressing, putting on and taking off footwear. R230 required set-up or clean-up assistance for oral care. R230's therapy care plan showed R230 had impaired ADLs (Activities of Daily Living) in the following areas: bathing, dressing, toileting, clothing management, and toileting hygiene. R230's nursing care plan showed R230 had an ADL functional performance deficit, activity intolerance, and decreased functional ability related to restless leg syndrome, overactive bladder, and polyarthritis. Interventions showed staff are to allow enough time form competition of ADL tasks, assist resident with oral care daily as needed, assist with ADL tasks as needed, and assist with personal hygiene as needed. On December 5, 2023, at 10:17 AM, R230 was in bed in a hospital gown, her hair was stringy and matted to her head. R230 also had long hairs on her chin. R230 said she has not had a shower since she was admitted to this facility, no one has offered to give her a shower, to shave her, or cut her nails. R230 stated she thought because they have to use a mechanical lift to get her out of bed, she could not have a shower. R230 also stated one staff member placed a special shower cap with a special shampoo in it on R230's head and then left the room. R230 said she was not able to swish it around to clean her hair. R230 said she would really like to have a shower, have her hair washed, and have 146153 Page 2 of 11 146153 12/07/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0677 someone shave her chin hairs. Level of Harm - Minimal harm or potential for actual harm On December 5, 2023, at 2:01 PM, R230 was in the occupational therapy room, her hair was stringy and matted to the back of her head. R230 continues to have long chin hairs that are approximately 1/4 inch on both sides of her chin. Residents Affected - Some On December 6, 2023, at 8:31 AM, R230 said her shower days are on Sunday and Thursday but since they have to use a mechanical lift to get her out of bed, R230 thinks she cannot have a shower. R230 said, no one has asked her if she would like to be shaved or have her nails cut. R230 said she also has an overactive bladder and they know it but they wait until she calls them to come check her incontinence brief. R230 said when she puts on her call light, it takes them a long time to answer it. On December 6, 2023, at 12:10 PM, V12 (CNA/Certified Nursing Assistant) and V13 (CNA) were getting R230 up out of bed for the day and into her wheelchair. R230 was wearing a hospital gown. R230 was dressed and then transferred from her bed into her wheelchair using a mechanical lift. V13 brushed R230's hair. V15 (Family Member) was in the room, and she asked V12 about getting R230's hair washed. V12 said they have a shower cap they can use that has shampoo in it. R230 told V12 they have tried it and she did not like it. V12 was asked if there was a reason R230 could not take a shower. V12 said most residents who require the use of a mechanical lift for transfers usually don't take showers because they are bed ridden. V12 said they do have a shower chair and it is possible to use a mechanical lift to place a resident in the shower chair just like they place them into their wheelchair. V15 and R230 both said they had no idea a shower was even an option. On December 6, 2023, at 1:01 PM, V15 said when she came in today, R230 had a dried crusty substance around both eyes and V15 said she asked R230 if she had brushed her teeth. R230 told her no, she had not brushed her teeth. V15 said R230 said she hasn't brushed her teeth in days or washed her face saying no one offers to help her get cleaned up in the morning. V15 said she gave R230 a wash cloth and helped set her up to brush her teeth in bed. On December 6, 2023, at 1:06 PM, V12 said when it is not a resident's shower day, we still check and change them, get them out of bed, help brush their teeth, brush their hair, and nail care. V12 said they will also put lotion on the resident's arms and legs, wash face, hands, armpits, and put on deodorant. V12 said her shifts starts at 11:00 AM and she did not know if V13 had provided any care to R230. On December 6, 2023 at 1:43 PM, V13 said the care provided depends on what the resident can do for themselves. We will help them wash face and hands, brush teeth, brush hair, perineal care, wash armpits, put on deodorant, and wash face. V13 said R230 can brush her hair, wash her face, and brush her teeth herself. On December 6, 2023, at 1:50 PM, V2 (DON/Director of Nursing) said we will always see what the resident can do for themselves, and the staff will help the resident with what they cannot do for themselves. V2 said residents should be checked and changed every two hours and her expectation is that every day; not just shower days, the residents are cleaned up, dressed and out of bed. Morning care consists of incontinence care or taking the resident to the bathroom, personal hygiene including brushing teeth, brushing hair, washing face, hands, armpits, applying deodorant, if resident has dentures, cleaning and putting dentures in the resident's mouth, nail care, and shaving (both men and women). If a resident is diabetic, the staff are only allowed to file the fingernails and not cut them. V2 said diabetics are referred to podiatry to have their fingernails cut. 146153 Page 3 of 11 146153 12/07/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Facility provided a policy dated March 10, 2022, and titled Dressing/Grooming. The policy showed Dressing/grooming refers to the activities provided to improve or maintain the resident's self-performance in dressing and undressing, bathing and washing, and performing other personal hygiene tasks. These activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record .c. Grooming: i. Maintaining personal hygiene; .iv. Combing hair; v. Washing face and hands; vi. Brushing teeth; vii. Shaving; viii. Applying deodorant; x. Trimming nails . Facility provided a policy dated September 2020, and titled Nails (Care Of). The policy showed All residents will have clean, well-trimmed nails. Procedure .5. Fingernails of diabetic residents are to be cut by the nurse . 146153 Page 4 of 11 146153 12/07/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that the resident's peri wound was cleaned prior to application of skin treatment. This applies to 1 of 5 residents (R65) observed for skin conditions in the sample of 19. Residents Affected - Few The findings include: The face sheet and physician order show that R65 is 94 years-old who has multiple medical diagnoses which include stage 3 pressure ulcer in the left and right buttocks and diaper dermatitis. In addition, there were multiple treatment creams (Lotrisone external cream, Nystatin-Triamcinolone external ointment, and Zinc Oxide Ointment 20 %) that was ordered for R65 due to skin condition. On December 5, 2023, at 10:22 AM, V6 (Wound Care Nurse) and V5 (Wound Care Technician) rendered wound care to R65's pressure ulcer. V6 cleansed the wound bed and the peri-wound with normal saline, then she applied treatment to the wound bed and covered it with dressing. When V6 completed the pressure ulcer treatment, V6 proceeded to apply combination of treatment creams (Lotrisone external cream, Nystatin-Triamcinolone external ointment, and Zinc Oxide Ointment 20 %) which were mixed together to R65's peri-wound. During the process of treatment application, R65 started urinating. The urine trickled down to R65's left lower buttock. V6 did not stop to clean the resident but instead V6 continued to apply the treatment creams. As a result the urine was getting mixed with the treatment creams and getting spread on the peri wound. V6 stated that R65 has a neurogenic bladder, and it was normal for her to urinate while being turned/reposition or while being provided care. On December 5, 2023, at 4:15 PM, V6 (Wound Care Nurse) stated that R65 has fungal rash in the sacrum, peri-wound, in the left and right buttocks and the groins. She has treatment creams such as Lotrisone, Nystatin, Triamcinolone, and Zinc which she mixes to apply to R65's affected area. On December 6, 2023, at 10:13 AM, V2 (Director of Nursing/DON) stated that when staff are providing wound or skin care and the resident had bladder or bowel incontinence, the staff should provide peri-care right away before they continue the skin or wound care. V2 also stated that staff are to ensure that skin is completely clean prior to applying treatment to prevent worsening of skin breakdown or skin problem. There was no specific care plan addressing R5's fungal rash condition. 146153 Page 5 of 11 146153 12/07/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer tube feeding as ordered by the physician. This applies to 1 of 1 resident (R60) reviewed for tube feeding in the sample of 19. The findings include: R60 had multiple diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysarthria and aphasia following cerebral infarction and type 2 diabetes mellitus without complications, based on the face sheet. R60 was admitted to hospice care on June 28, 2023 with terminal prognosis of CVA (Cardiovascular accident). R60's quarterly MDS (minimum data set) October 11, 2023 showed that the resident was cognitively impaired. The same MDS showed that R60 uses feeding tube for nutrition. On December 4, 2023 at 10:32 AM, R60 was sleeping in bed with head of bed elevated. R60 had an ongoing gastrostomy tube feeding of Isosource 1.5 cal (calorie) running at 65 ml (milliliters)/hour as set by the feeding pump. The 1000 ml closed system of Isosource bag that was being used had a label indicating that it was started on December 4, 2023 at 10:00 AM to run at 65 ml/hour. On December 5, 2023 at 10:30 AM, R60 was in bed, awake but non-verbal. R60 had an ongoing gastrostomy tube feeding of Isosource 1.5 cal running at 65 ml/hour as set by the feeding pump. The 1000 ml closed system of Isosource bag that was being used had a label indicating that it was started on December 5, 2023 at 5:00 AM to run at 65 ml/hour. On top of R60's bedside table was an unused 1000 ml tube feeding bag of another Isosource 1.5 cal. R60's active order summary report showed an order dated August 12, 2023 for, NPO (Nothing By Mouth) diet. The same active order summary report showed an order dated August 13, 2023 to infuse 65 ml/hour of Diabetisource 1.2 cal tube feeding, every shift. On December 5, 2023 at 10:35 AM, V3 (Registered Nurse) was asked to check R60's tube feeding. V3 confirmed that the tube feeding that was being delivered to R60 at the time was Isosource 1.5 cal. V3 also confirmed that there was an unused Isosource 1.5 cal tube feeding bag on top of R60's bedside table. V3 was prompted to check R60's tube feeding order, and had confirmed that R60 should receive the ordered Diabetisource 1.2 cal at 65 ml/hour, instead of the Isosource 1.5 cal. According to V3, R60 should receive the Diabetisource 1.2 cal because the resident was diabetic. V3 further stated that she had reviewed R60's active orders and there was no order to change the tube feeding and/or may administer a different tube feeding aside from the ordered Diabetisource 1.2 cal. At 10:40 AM, V3 went inside the unit supply/storage room and 2 bags of Diabetisource 1.2 cal 1000 ml was available in the unit for use. R60's monthly enteral assessment dated [DATE] created by V4 (Registered Dietitian) showed in-part, NPO status. Currently receiving Diabetisource [at] 65 ml/hr (hour) x 24 hours with [water] flush 200 ml [every] 6 hours. Tolerating feeding well. Appears to be well hydrated and nourished. Enteral 146153 Page 6 of 11 146153 12/07/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feeding will provide [R60] with 1872 kcals (kilocalories), 94 g (grams) protein, 1276 ml free water with a total of 2076 ml fluid daily. Enteral feeding will provide [R60] with 100% of energy and hydration needs. The same assessment showed in-part under recommendations, continue enteral feeding as ordered. R60's active care plan initiated on June 7, 2023 showed that the resident was on NPO and required tube feeding. The same care plan showed multiple interventions including administration of tube feeding per physician order. On December 6, 2023 at 10:12 AM, V4 stated that R60 was diabetic and based on her calorie computation, the resident was appropriate to receive Diabetisource 1.2 cal to maintain weight and blood sugar level. According to V4, since R60 was diabetic and on NPO, R60 should receive her ordered tube feeding to ensure proper nutrition and hydration. V4 added that R60, does not need a higher calorie feeding based on the resident's weight and calorie computation. On December 6, 2023 at 10:36 AM, V2 (Director of Nursing) confirmed that the nurses had administered wrong tube feeding to R60 as observed on December 4 and 5, 2023. V2 stated that the nurses' are expected to always follow the physician's orders for tube feeding. The facility's clinical practice guidelines regarding enteral nutritional feeding dated September 2020 showed in-part under procedure, 1. Verify M.D. (Medical Doctor) orders for feeding. 146153 Page 7 of 11 146153 12/07/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 provide a resident with an opioid pain medication or muscle relaxant pain medication as prescribed by the physician. This applies to 1 of 4 residents (R69) reviewed for pain management in the sample of 19. Residents Affected - Few The findings include: R69's EMR (Electronic Medical Record) showed R69 was admitted to the facility on [DATE], with multiple diagnoses including, lumbar spondylolisthesis (spinal displacement), lumbosacral spinal stenosis (narrowing of the spinal cord), and arthrodesis (joint fusion). R69's MDS (Minimum Data Set) dated November 3, 2023, showed R69 was cognitively intact. The MDS continued to show R69 had pain in the last five days. R69's pain care plan dated October 28, 2023, showed Alteration in comfort: spinal stenosis and spondylolisthesis status post lumbosacral fusion. The care plan continued to show multiple interventions dated October 28, 2023, including Administer pain strategies according to Medication Administration Record and Treatment Administration Record. On December 4, 2023, at 10:17 AM, R69 said she was admitted on [DATE], and did not receive pain medication until the morning of October 29, 2023. R69 continued to say she had a difficult time participating in therapy because of her pain. V18 (R69's Daughter) said she asked R69's nurse about R69's pain medication and was told the medication would not be delivered to the facility at 3:00 AM. V18 continued to say she asked R69's nurse if the facility has an extra supply of pain medication and was told by the nurse the facility did not have R69's pain medication available. On December 5, 2023, at 1:59 PM, R69 said she was taking pain medication regularly while she was in the hospital prior to being admitted to the facility because she had spinal surgery on Wednesday, October 25, 2023. R69 continued to say when she arrived to the facility on Saturday night, she asked for pain medication throughout the night and only received acetaminophen. R69 said the acetaminophen did not work as well as the other pain medications. R69 said prior to her back surgery, she was taking tramadol four times a day for pain relief. R69's Physical Therapy Evaluation and Plan of Treatment, dated October 29, 2023, at 12:56 PM, by V19 (Registered Physical Therapist) showed R69 said I know I could do more if the medicine works and if I am not in a lot of pain. On December 6, 2023, at 11:06 AM, V11 (Director of Pharmacy Operations) said if medications are ordered for a resident and requested for pharmacy delivery around 4:00 PM to 5:00 PM, then the medications will be delivered to the facility the following day between 2:00 AM and 3:00 AM. V11 continued to say the facility maintains a supply of pain medications in their automated medication dispenser which can be used prior to medication delivery. V11 said facility staff are also able to request a stat medication delivery. V11 said R69's tramadol and oxycodone-acetaminophen were delivered to the facility on October 29, 2023, at 2:00 AM. On December 6, 2023, at 9:47 AM, V9 (RN/Registered Nurse) said she was R69's nurse on October 28, 2023, when she was admitted . V9 continued to say if medications are ordered after 3:00 PM, then they 146153 Page 8 of 11 146153 12/07/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few will be delivered at 3:00 AM the following day. V9 continued to say if a resident was requesting pain medication before the delivery V9 would check the automated medication dispenser for the medication and if the medication was not in there then she would get an order for acetaminophen. V9 said she had never made a stat request for medication from the pharmacy. On December 6, 2023, at 1:29 PM, V2 (DON/Director of Nursing) said oxycodone-acetaminophen, tramadol, and tizanidine were in the automated medication dispenser. V2 continued to say R69 should have received the prescribed pain medications instead of the acetaminophen. The facility's undated Inventory List for [the facility], showed the facility had medication stock of oxycodone-acetaminophen, tramadol, and tizanidine. R69's October 2023 MAR (Medication Administration Record) showed R69 had medication orders dated October 28, 2023 for oxycodone-acetaminophen (opioid pain medication) 5/325 mg (milligram) oral tablet, give one to two tablets by mouth every six hours as needed for pain management; tramadol (opioid pain medication) 50 mg oral tablet, give one tablet every 12 hours as needed for pain management; and tizanidine (muscle relaxant) 2 mg oral tablet, give one tablet every six hours as needed for muscle weakness. R69's MAR continued to show R69 first received oxycodone-acetaminophen on October 29, 2023, at 5:57 AM, and first received tramadol on October 29, 2023, at 8:22 AM. R69's hospital documentation titled After Visit Summary, dated October 28, 2023, at 2:04 PM, showed R69 last received oxycodone-acetaminophen on October 28, 2023, at 11:58 AM, last received tramadol on October 25, 2023, at 8:09 PM, and last received tizanidine on October 28, 2023, at 4:52 AM. The documentation continued to show discharge instructions of take pain medication (oxycodone-acetaminophen) as needed for pain. R69's Pain Management Evaluation dated October 28, 2023, at 6:22 PM, showed R69 had undergone a painful procedure and had almost constant pain over the last five days. R69's Weights and Vitals Summary dated December 6, 2023, showed on October 28, 2023, at 6:01 PM, R69 complained of 6/10 (moderate) pain. The documentation continued to show R69 was not pain free until October 29, 2023, at 2:10 PM. 146153 Page 9 of 11 146153 12/07/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

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. On December 5, 2023, at 11:27 AM, V6 (Wound Nurse) and V5 (Wound Care Technician) rendered incontinence and wound care to R5 who was heavily saturated with urine and had a bowel movement. V6 cleaned R5's rectal and buttocks area while V5 cleaned the frontal perineum. After V5 completed the peri-care, she continued to assist with positioning R5 for wound care, straightened R5's clean gown, bed linen and pillow while wearing the same soiled gloves. Residents Affected - Few On December 6, 2023, at 10:09 AM, V2 (Director of Director/DON) stated that staff must perform hand hygiene before and after providing care. They should also change gloves and perform hand hygiene in between task. This is done for infection prevention. 3. R230's EMR (Electronic Medical Record) showed R230 was admitted to the facility on [DATE], with diagnoses that included fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing, polyneuropathy, peripheral vascular disease, overactive bladder, and restless leg syndrome. R230's admission MDS (Minimum Data Set) dated December 1, 2023, showed R230 was cognitively intact. R230's functional abilities on admission showed she was dependent on staff for toileting, shower/bath, upper body dressing, lower body dressing, putting on and taking off footwear. R230 required set-up or clean -up assistance for oral care. R230 had been at the facility for less than two weeks at the time of this survey and assessments were still ongoing. R230's therapy care plan showed R230 had impaired ADLs (Activities of Daily Living) in the following areas: bathing, dressing, toileting, clothing management, and toileting hygiene. R230's nursing care plan showed R230 had an ADL functional performance deficit, activity intolerance, and decreased functional ability related to restless leg syndrome, overactive bladder, and polyarthritis. Interventions showed staff are to allow enough time form competition of ADL tasks, assist resident with oral care daily as needed, assist with ADL tasks as needed, and assist with personal hygiene as needed. On December 6, 2023, at 12:10 PM, (CNA/ Certified Nursing Assistant) and V13 (CNA) were getting R230 up out of bed and into her wheelchair but first provided incontinence care. V12 and V13 each opened one side of the incontinence brief. V12 used a wipe and wiped left groin, folded wipe and wiped right groin, folded the wipe and wiped down the middle. With the same gloves, V12 repositioned R230 onto her left side (facing away from her and towards V13). V12 then rolled up the wet brief and placed it under R230. V12 used a wipe to clean R230's anal area. While wearing the same gloves V12 started with, V12 picked up and placed a clean incontinence brief under R230 and then repositioned R230 onto her right side, now side facing V12. V13 pulled the clean brief through and positioned it under R230. V12 and V13 both while still wearing the same gloves repositioned R230 onto her back. V12 and V13 fastened the incontinence brief. V13 grabbed the lotion and applied lotion to R230's left leg. V13 removed her gloves and without performing hand hygiene, put on a new pair of gloves. V13, put lotion into her hand and rubbed lotion onto R230's right leg. On December 6, 2023, at 1:50 PM, V2 (DON/Director of Nursing) said when staff are providing incontinence care or perineal care, they are to remove the incontinence brief, clean all areas front to back, cleaning each area with a different rag or wipe, if they fold rag or wipe in half that is ok, but V2 said her expectation is that they fold it no more than two times. The area needs to be dried well so there is no moisture. When done cleaning the front area, the staff need to remove gloves, 146153 Page 10 of 11 146153 12/07/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few perform hand hygiene, and reapply new gloves before turning the resident onto their side to clean the back side. The back side will get cleaned from front to back. When staff are done cleaning the back side, they need to remove gloves, perform hand hygiene, and put on new gloves before touching the new incontinence brief and continuing with the rest of the resident's care. Facility provided policy dated June 4, 2020 and titled, Hand Washing and Hand Hygiene. This policy showed Purpose of hand hygiene is essential in preventing the spread of infectious organisms in healthcare settings. The Guidelines include 1. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items b) Before contact with a particularly susceptible resident (open wounds, etc.) .d) Before and after touching wounds of any kind. e) Before and after providing personal care for a resident. f) After removing gloves Based on observation, interview, and record review, the facility failed to follow their policy and don recommended personal protective equipment (PPE) while performing wound care to a resident on Enhanced Barrier Precautions (EBP). The facility also failed to follow their policy by not removing soiled gloves after performing incontinence care, and not performing hand hygiene before touching the resident's clean environment. This applies to 3 of 19 residents (R47, R5, and R230) reviewed for infection prevention in the sample of 19. The findings include: 1. R47's face sheet documents a stage 4 sacral pressure ulcer with an onset date of 11/5/2022. R47's skin care plan documents he has an actual alteration in skin integrity related to sacral pressure ulcer. Intervention: Enhanced Barrier Precautions will be implemented during high contact resident care activities for chronic wounds including, but not limited to pressure ulcers. On December 5, 2023 at 9:34 AM with V5 (CNA) and V6 (Wound Care Coordinator) outside R47's room, there is bright orange EBP sign on R47's door that shows staff should wear a gown and gloves during wound care for any skin opening requiring a dressing. V6 and V5 did not put on a gown before providing wound care to R47. V5 removed R47's brief, and repositioned R47 onto his left side during the wound care. R47 had an open wound to his sacrum that was about the size of a quarter. V6's scrubs cames in contact with the resident's bed linens while performing his wound care. After the provision of wound care to R47, V6 stated that she and V5 should have worn a gown before providing wound care to R47 who is on enhanced barrier precautions. On December 6, 2023 at 08:52 AM, V2 (Infection Preventionist/DON) stated that she expects the staff to be 100% compliant with donning gown and gloves when performing wound care to residents on Enhance Barrier Precautions. V2 stated that using gown and gloves during wound care is necessary to protect the resident from getting an infection. The facility's EPB policy dated April 10, 2023 shows the following: In addition to standard precautions, enhanced barrier precautions, will be implemented during high-contact resident care activities when caring for residents with a novel or targeted Multidrug Resistant Organisms (MDRO), chronic wounds or indwelling medical devices. Wound Care: any chronic wound requiring a dressing: The intent of Enhanced Barrier Precautions is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. 146153 Page 11 of 11