Health inspection·April 24, 2025

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 follow contact isolation protocols by failing to place correct signage on resident room door regarding isolation precautions, they failed to ensure that a resident on contact isolation was placed in an appropriate room, and they failed to ensure that a resident's breathing mask was properly contained in accordance with infection control protocols. These failures applied to two (R3 and R4) of six residents reviewed for infection control. Residents Affected - Few Findings include: R4 is [AGE] years old and have resided at the facility since 2019. Face sheet listed the following medical diagnosis among others: Local infection of the skin and subcutaneous tissue, abnormal posture, personal history of malignant neoplasm of the bladder, dependence on renal dialysis, methicillin resistant staphylococcus aureus infection as cause of disease classified elsewhere, methicillin resistant staphylococcus aureus infection unspecified site, pressure induced deep tissue damage of contagious site of back, buttock, and hip etc. 04/22/25 1:15AM, R4 was observed in his room with another resident (R3) sharing the same room. An enhanced barrier precaution signage was noted at the door and some personal protective equipment (PPE) was noted behind the door. R4 was sitting on a motorized wheelchair, awake, alert and oriented and stated that he is doing okay. R4 said that he gets wound care at night, they do it when he lays down and it is okay with him. R4 added that he gets breathing treatment and normally does it himself after breakfast or before, he also takes his two inhalers after the breathing treatment. A breathing machine was noted at the bedside with the breathing mask open to air and not contained. R4 was observed during the survey moving around the facility in his motorized wheelchair and even attended the resident council meeting held by a surveyor. R3 is [AGE] years old, admitted to the facility on [DATE], medical diagnosis includes, but not limited to presence of urogenital implants, unspecified dementia, unsteadiness on feet, type 2 diabetes, retention of urine, presence of aortocoronary bypass graft, etc. Review of facility list for residents on isolation dated February 2025 listed R4 as being on contact isolation for MRSA of wound and C-diff. Isolation was started on 2/24/2025 and the end of isolation was documented as on going. Care plan initiated 3/1/2025 states: R4 is on contact isolation d/t MRSA/ C diff. Goal states: R4 will remain in his room while on contact isolation. Staff will adhere to the contact isolation while providing care to prevent spread of infection. Interventions include Provide education to the resident as able and family on Contact Isolation protocol and rationale, Staff to wear PPE's when providing care per facility protocol. Mask/eye shield as indicated for Page 1 of 2 146199 146199 04/24/2025 Three Crowns Park 2323 McDaniel Ave Evanston, IL 60201

F 0880 potential splashing/contamination, etc. Level of Harm - Minimal harm or potential for actual harm 04/23/25 11:30AM, V3 (infection prevention nurse) said that R4 used to be on contact isolation for MRSA of the wound, he went to the hospital and the isolation was discontinued at the hospital. Resident is just on enhanced barrier precaution now, the admitting nurse called the hospital who told her that that the isolation was discontinued, V3 told the nurse to document the information from the hospital. Residents Affected - Few Review of resident's record did not show any physician order or progress note stating that R4's contact isolation was discontinued. Surveyor requested for the information from facility, but none was provided. On 4/24/2025 at 12:16PM, V2 (DON) said that they could not fid any documentation that R4's contact isolation was discontinued. V2 added that R4 should have been in a private room and the contact isolation precaution sign should have been placed on the door. V2 also said that residents breathing masks should be contained after use. Transmission based precaution policy provided by V2 (DON) revised September 2022, states that transmission-based precaution are initiated when a resident develop signs and symptoms of transmissible infection, arrives for admission with symptoms of infection or have laboratory confirmed infection ad is at risk of transmitting the infection to other residents. Under contact precaution, the policy states in part that contact precautions are implemented for residents known or suspected to be infected with microorganisms 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. Contact precautions are also used in situations when a is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen even before a specific organism has been identified. Under discontinuation of isolation the policy states that transmission-based precaution is discontinued when it is determined that the resident's condition no longer indicate such precaution. Residents remains on appropriate transmission-based precaution until discontinued by the attending physician or the infection preventionist. 146199 Page 2 of 2