Health inspection·January 24, 2025

F 0656 the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their restorative care policy and provide restorative therapy for one (R18) in a total sample size of 12 resident. Findings include: On 01/21/25, at 1:10 PM, R18 sitting on his wheelchair, in the activity room, and in no apparent distress. R18 unable to be interviewed. R18's left hand constricted. On 01/21/25, at 1:11 PM, V10 (certified nursing assistant) states that R18 tends to flinch his hands and makes fists. On 1/23/2025, at 2:04 PM, via telephone V32 (Licensed Practical Nurse/Minimum Data Set nurse) states that some common Parkinson's disease signs and symptoms can include tremors, they can decline functionally. V32 states that some interventions that can be put in place for a resident with Parkinson's disease can include- monitor for tremors, if they have side effects of the medication, PT/OT (physical therapy/occupational therapy) when we think they need help, doing range of motion for them to maintain the current function to prevent contractures. On 1/23/25, at 3:17 PM, V30 (Director of Rehab) states that she has not worked for the facility long (since December 10th, 2024). V30 reports that R18 is not being followed by therapy. On 1/23/2025, at 4:24 PM, V3 (Director of Nursing) states that V32 is covering for the restorative therapy since the previous nurse is on vacation. V3 states that the purpose of restorative program is to maintain the resident at their baseline. V3 states that a resident with a primary diagnosis of Parkinson's Disease will benefit from a restorative program because it can slow the decline. V3 states that a restorative program is specific for whatever the resident is assessed for and there are specific goals. V3 states that residents are referred to restorative when they get discharged from rehabilitation services such as physical therapy. V3 states but they will have all residents try to do some restorative program. V3 states that a patient diagnosed with Parkinson's disease can develop contractures especially if they are not able to move around anymore. V3 states I think he (R18) absolutely will benefit from restorative therapy. V3 states that she cannot tell this surveyor the rationale as to why R18 is not being provided with restorative therapy services. R18's face sheet documents R18 is an [AGE] year-old individual admitted to the facility on [DATE] with the following diagnoses but not limited to secondary Parkinsonism, unspecified, muscle weakness, dementia. R18's Minimum Data Set (MDS) Section C, dated 1/5/2025, documents R18 is rarely/never understood. R18's Minimum Data Set (MDS) Section I, dated 1/5/2025, documents R18 has diagnosis of Parkinsonism, unsteadiness on feet, repeated falls, muscle weakness. R18's MDS section O Special Treatments, procedures, and programs, dated 1/5/2025, documents in part that R10 received 0 days of restorative nursing programs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 R18's current care plan does not document restorative therapy interventions. Level of Harm - Minimal harm or potential for actual harm R18's physician order set does not document an order for restorative therapy. Residents Affected - Few Facility document undated, titled Restorative Program notes a list of residents that are on a restorative program, and R18 is not noted on the list of residents that are on a restorative program. Facility document dated 12/2024 titled Restorative Nursing Services documents in part residents will receive restorative nursing care as needed to help promote optimal safety and independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to ensure a safe, hazard free environment for 15 residents residing on the eighth floor of the 29 residing in the facility. Residents Affected - Some Findings include: On 1/21/25, at 9:54 AM, while touring the 8th floor, writer observed four screws on the floor in the hallway. Writer observed two staff members, V20 (Live Enrichment) and V21 (Care Partner/Certified Nursing Assistant-CNA) walk past the screws on the floor without picking them up. On 1/21/25, at 10:07 AM, V22 (Maintenance) was observed picking up the four screws from the floor in the hallway. V22 verified to writer that they are screws. V22 stated I picked them up, so no one has an accident. Someone could step on them and slip and fall. They should not have been on the floor. I don't know who left them there. There have been no calls to me to pick them up. Staff should have picked them up to prevent a hazard. On 1/23/25, at 2:50 PM, V3 (Director of Nursing) stated we keep the supply room with medication and supplies locked. Anything hazardous to the resident is locked, especially in the kitchen. Anything harmful to the resident is kept out of reach. To be free of hazards, we make sure no clutter is on the floor, no loose carpet. The passageway is clear of anything to make trip, we have adequate lighting. There should not be anything in the hallway to make the resident trip. Equipment should be kept on one side of the hallway. There should not be screws on the floor of the hallway. If there is they should be picked up by any staff member. The resident can easily slip on them, harm themselves, poke themselves. If I see a screw on the floor, I have to pick it up. According to facility daily census 1/22/2025, provided by facility, there are 15 residents that reside on the eighth floor. According to 10 Fall Prevention Tips for Seniors posted on the 8th and 10th floors of the facility, the first tip is to remove tripping hazards such as books and papers, shoes, and boxes from stairs and hallways, and secure rugs. Facility policy Safety and Supervision of Residents, 12/2024, documents in part: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing bases through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 accurately secure controlled substance medications for two residents (R7 and R14) in a sample of 12 reviewed for medication/controlled substance storage. Findings include: 1/21/25, at 10:43 AM, reviewed 8th floor medication cart and medication room with V23 (Licensed Practical Nurse-LPN). Observed V23 open the refrigerator and narcotic lock box without using a key or entering a code or any other unlocking method. Observed the refrigerator to have no locking mechanism. Observed the narcotic lock box inside of the refrigerator to have a coded locking mechanism. V23 verified to writer the narcotic lock box was not locked with the coded locking mechanism. Inside of the unlocked narcotic lock box was Lorazepam Intensol Oral Concentrate 2mg (milligrams) per ml (milliliter) for R7 and R14. 1/21/25, at 11:30 AM, V23 (Licensed Practical Nurse-LPN) stated narcotics should be locked so accessible only to the nurse; to keep them safe. 1/23/25, at 2:50 PM, V3 (Director of Nursing) stated narcotics need to be double locked. The narcotic box should be locked, and the medication cart is locked when unattended. In the medication room, the medication room should be locked and the narcotic box inside of the refrigerator should be locked. The refrigerator is not locked. The narcotics are locked because they are controlled substances. We keep it locked to keep them from going missing, so residents can't get to them and overdose. R7 physician order summary reads in part: Lorazepam Oral Concentrate 2mg/ml Give 0.25 milliliter by mouth every 2 hours as needed for mild to moderate anxiety, active order status, start date 11/11/2024. Lorazepam Oral Concentrate 2mg/ml Give 0.25 milliliter by mouth one time a day for anxiety, active order status, start date 11/11/2024. Lorazepam Oral Concentrate 2mg/ml Give 0.5ml by mouth every 2 hours as needed for severe anxiety, active order status, start date 11/11/2024. R14 physician order summary reads in part: Lorazepam Intensol Oral Concentrate 2mg/ml Give 0.25 milliliter by mouth every 2 hours as needed for anxiety or nausea for 14 days, active order status, start date 1/22/2025, end date 2/5/2025. Lorazepam Intensol Oral Concentrate 2mg/ml Give 0.5ml sublingually every 2 hours as needed for moderate to severe anxiety or nausea for 14 days, active order status, start date 1/22/2025, end date 2/5/2025. Facility policy Controlled Substances, 11/2022, documents in part: Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow their policies and implement safe food preparation and services to ensure the food conserves a safe temperature. This failure has the potential to affect all residents that receive nutrition from the kitchen. Residents Affected - Many Findings include: On 1/21/2025 at 9:38 AM, this surveyor reviewed facility dated 1/21/2025 titled Hot holding (main kitchen) temperature log does not document a temperature was taken for the breakfast food (scrambled eggs, scrambled eggs puree, breakfast meat, breakfast meat puree, oatmeal, oatmeal puree, cheese omelet, cheese omelet puree). On 1/21/2025 at 9:39 AM, V6 (Director of Culinary Services) states that it should be filled out before the food goes out. V6 states that it is important to know the temperature of the food because they won't know if they need to make corrections and have proper holding temperatures. V6 it's important for the residents' health and avoiding food-related illnesses. On 1/21/2025 at 12:32 PM, V8 (Supervisor for dining) states that there is a steamer on each floor, and V8 states but this floor's (8th floor) steamer is not working currently, and there is a work order for it. V8 report that the holding food temperature should be about 130 to 135 degrees Fahrenheit. V8 states that the food is being microwaved prior to being served to the resident. This surveyor asked V8 to check the temperature for the barbeque beef and V8 utilized the facility's thermometer to properly measure the temperature. V8 states and this surveyor observed the temperature read 90 degrees Fahrenheit. V8 states that the food should be covered also to prevent dust or insects from entering to the food. On 01/22/2025 at 10:08 AM, with V6 (Director of Culinary Services) states that staff are not supposed to remove the hot food out of the hot boxes (insulated food carriers). V6 continues to state the servers are supposed to serve form the insulated food carriers. V6 states that this is the process that is being done as of now due to the steamer table is not working currently and there is a work order. V6 states that she is just waiting to hear back on the quote to fix it. V6 states that V8 (Supervisor for Dining) is responsible to monitor during the dining services. Facility document not dated documents in part the mealtimes for the skilled floors, breakfast is from 8:00 AM to 9:30 AM. Facility document dated January 2021 documents in part Recording Temperatures, purpose: to ensure all food is prepared at appropriate temperatures and served at correct holding temperatures. The cook is responsible for checking the cooking temperature of each food item: meat, starch, vegetable, etc. The temperature will be taken with calibrated thermometer. The cook will determine if final temperature of each food is at a safe temperature to serve. Facility document dated 11/2010 documents in part Critical Food Temperature Guide, food storage temperatures. Food held in the danger zone temperatures range may cause illness. Danger zone temperatures are from 40 degrees Fahrenheit through 140 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 and label food items in accordance with professional standards for food service safety and follow proper sanitation and food handling. This failure has the potential to affect all residents that receive nutrition from the kitchen. Findings include: On 1/21/2025 at 9:53 AM in the refrigerator with V6 (Director of Culinary Services), was approximately 20 slices of cheese slices dated 1/13 use by 1/20, approximately 15 slices of turkey dated 1/13 use by 1/20, the tail end of cured Italian meat prepared 10/5/2024 with use by 1/10/2025. A Three 5-pound containers of cottage cheese that expired on 1/20/2025. On 1/21/2025 at 10:10 AM in the walk-in freezer with V6 was a blue cheese butter labeled 10/05/2024 use by 1/20/2025, approximately 12 pieces of prepared chicken on a silver tray covered with plastic cover, labeled 10/20/2024 use by 1/1/2025. V6 states these food items should have been discarded. V6 states that she is working on in-servicing the kitchen staff. On 1/21/2025 at 11:26 AM there were several pieces of zucchini on a cart, uncovered, and no staff around the pieces of zucchini. V6 continues to state if the staff took it out, it should be covered due to potential for contamination. With V6, 12 slices of lemon bars uncovered and no staff around the slices of lemon bars. On 1/22/2025 at 9:55 AM there were 6 large soup containers on a table with ice, uncovered, no lids noted in the area. On 1/21/2025 at 12:28 PM V9 (server) was serving a lunch tray that is being prepared to be delivered to a resident. V9 was not wearing a hairnet. Three pans noted on the steam table, without lids or plastic covering the food. One pan was barbeque beef, another pan was peas and carrots. Facility document dated January 2/2020 documents in part Refrigerated Storage. Purpose to ensure all food products are safe and to prevent foodborne illnesses. All food is labeled, if taken out of original packages, food will be labeled and dated. Facility document dated January 12/2024 documents in part Freezer Food Storage. Purpose to be sure all frozen food products are served in a timely manner and are of the highest quality. Store food in its original package, when possible, if taken out of original package should be labeled and dated and tightly wrapped. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 observe proper PPE (Personal Protective Equipment) protocols. This failure has the potential to affect all residents residing in the facility. Residents Affected - Many Findings include: 1. On 1/21/25, at 12:30 PM, observed a sign posted on R19's door frame. The sign had two STOP signs pictured and the CDC (Centers for Disease Control and Prevention) emblem on it. The sign read in part: Contact Precautions. Providers and staff must also: put on gloves before room entry. Put on gown before room entry. V24 (R19 Private Care Giver) was observed inside of R19's room with no PPE (Personal Protective Equipment), gown, gloves worn. On 1/21/25, at 12:33 PM, V24 (R19 Private Care Giver) stated R19 is a two-person assist. V24 cleans R19's face, brushes R19's teeth, puts clothes on R19 and helps the Care Partners-CNA's change R19. V24 works weekdays and sits inside R19's room for companionship and to monitor. V24 stated V24 only wears PPE (Personal Protective Equipment), gown, gloves when V24 changes R19 after a bowel movement. V24 stated a nurse told R19 that R19 has to be on quarantine for ten days for something dealing with the bowel. V24 stated that V24 was told PPE was not needed just to be inside of the room, only to change the adult brief. On 1/21/25, at 2:10 PM, V3 (Director of Nursing) stated on contact precaution, you wear the necessary PPE to go into the room which includes gown and gloves. This includes everybody that goes into the room. The caregiver should have on a gown and gloves when they are in the room even if just sitting. They are touching things in the room so they should have on PPE. On 1/21/25, at 3:10 PM, V12 (Infection Control Prevention Nurse-RN) stated R19 is on contact precaution for CDIFF (Clostridioides difficile). R19 has been on contact precaution since 1/13/25, and is due to come off 1/22/25. Contact precaution is for infections passed by touching. CDIFF can be transferred to objects in the room such as the bedside table, call light, television remote control. Staff are supposed to gown and glove whenever they change (change adult brief, clean up after a bowel movement) the resident. If any nurse, CNA (Care Partner) and care giver have any contact (touching, changing adult brief, any contact with bodily fluids) with R19 then they should gown and glove up. If anyone is not touching the resident, then they do not need to gown and glove. If a care giver is just sitting in the room they do not need to gown and glove. If the care giver is touching the resident, then they gown and glove. It is possible for the care giver and anyone else that goes into the room to come into contact with the bedside table, call light, television remote control, etc. and thereby come into contact with CDIFF. The reason for contact precaution is to protect others from the infection. The PPE is to protect the staff and others from the infection of the contact precaution. If the staff or anyone else is not wearing PPE while in the room for any reason they are at risk to contact CDIFF. R19 progress note, 1/13/2025, 3:21 PM, reads in part: Resident tested positive for C-diff. (Physician) notified with order to start vanco 125mg (milligrams) Q (every) 6 PO (by mouth) times 10 days. Order carried out, isolation precautions set up and POA (power of attorney) notified of isolation precautions . R19 progress note, 1/14/2025, 6:35 PM, reads in part: Positive for c-diff. On contact isolation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 (until 48 hrs after last episode of diarrhea resolution) Level of Harm - Minimal harm or potential for actual harm Facility policy Isolation-Categories of Transmission-Based Precautions, no date, documents in part: Contact precautions are implemented for residents known or suspected to be infected with microorganism that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors wear gloves (clean, non-sterile) when entering the room. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Residents Affected - Many 2. On 01/23/2024, at 10:36 AM, V26 (Housekeeping) was observed on her phone going from the eighth floor to the elevator wearing disposable gloves, and did not have a cleaning cart. V26 used her gloved hands to choose the floor she was going to. V26 stated she was in a rush and forgot to remove her disposable gloves and got off the elevator on the seventh floor. On 01/23/2025, at 11:17 AM, V26 stated she had gloves on because she was in a hurry to assist two temporary workers and they kept calling her to assist them. V26 stated she was trained to wear gloves only in the residents' rooms then take them out before leaving the resident room then wear clean ones in the next room. V26 stated wearing gloves outside the resident's room posed a risk of spreading germs and is risk for contamination. V26 stated she had infection control in-service last year but she does not remember when. On 01/23/2025, at 1:01 PM, V28 (Assistant Director of Nursing-ADON) stated staff are not supposed to walk around wearing disposable gloves because that would be spreading germs throughout the facility. V28 stated house keepers should be wearing gloves inside the resident's rooms while cleaning and take them out before leaving the residents room and not wear them while walking in the hallways and in the elevator to prevent spread of germs. V28 stated staff are provided in-services to make sure they are aware of how to prevent spread of germs. On 01/23/2025, at 1:17 PM, V12 (Infection Control Nurse-LPN) stated staff, including housekeepers are not supposed to walk in the hallways, elevators and other floors wearing disposable gloves to prevent the spread of germs and diseases in the facility, and the germs can spread around the units which can spread to residents. On 01/23/2025, at 1:41 PM, V29 (Environmental Service Housekeeping Manager) stated house keepers are not supposed to walk around wearing disposable gloves in the units and hallways because they can spread germs which can affect the residents. V29 stated housekeepers are supposed to remove disposable germs once they are done with a resident room and put the dirty gloves in the garbage bin. V29 stated she trains her staff once a year on infection control. V29 stated in-service is provided by an outside vendor but she does not have the information or sign in sheet for staff who attended from the last time the class was provided. Personal Protective Equipment -Using Gowns dated 2001 documents: -After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 10 of 10