Inspection·January 27, 2023

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 provide care to to residents with indwelling urinary catheters to prevent UTI's (Urinary Tract Infections) for 2 of 2 sampled residents (R63, R69) in a sample of 26. Findings Include: 1. R99's face sheet shows an admission date of 12/30/22, with primary diagnosis of urinary tract infection. R99's MDS (Minimum Data Set) shows R99 is cognitively intact and requires extensive assistance for toileting/catheter care. R99's care plan, dated 12/30/22, shows R99 has urinary tract infection sepsis diagnosis, utilizes an indwelling catheter, and is at risk for complications including recurrent urinary tract infections, urosepsis, renal damage, and skin breakdown. On 1/26/23 at 9:21AM, V11 (Certified Nurse Assistant/CNA) was observed providing urinary catheter care for R99. While cleaning the tubing, V11 held the catheter tubing midway between the tip of the penis and the drainage bag with one hand, and cleaned down from that hand towards the tip of the penis. V11 did this motion more than three times with same wipe cleaning catheter tubing towards the tip of the penis. V11 said she does this catheter care twice a shift. On 1/26/23 at 9:27AM, V10 (R99's nurse) said when providing catheter care, the tubing should be wiped away from the resident's body. V10 said you start with the wipe at the tip of the penis and clean down towards the drainage bag. On 1/26/23 at 9:58AM, V2 (DON/Director of Nursing) said the cleaning of the catheter tubing should be away from the resident, from the tip of the penis towards the drainage bag. Facility policy titled Urinary Catheter Care Policy and Procedure, (September 18, 2019) reads: Procedure 16. For the male resident . 17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. 2. R63's face sheet showed R63 was admitted to the facility on [DATE], with the following diagnoses: urinary tract infection, hemiplegia and hemiparesis, muscle weakness, acute cystitis, bacteremia, and cognitive communication deficit. R63's MDS (Minimum Data Set) shows R63 is cognitively intact and requires extensive assistance for bed mobility, toileting, and personal hygiene. R63's care plan, dated 12/9/22, showed R63 had a self-care deficit and required assistance from staff for activities of daily living. R63's care plan also showed R63's urinary catheter bag should not touch the floor. On 1/25/23 at 8:36 AM, V8 (Wound Treatment Nurse) and V9 (Wound Treatment Nurse) provided wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 2 of 3 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few treatment to R63. R63's indwelling urinary catheter bag was observed on the ground. V8 and V9 opened R63's incontinence brief and saw that R63 had a bowel movement. V8 cleaned the resident's buttocks, but did not turn resident onto her back to provide care for R63's perineal area. V8 did not check if R63's urinary catheter tubing contained stool, and did not clean R63's urinary catheter tubing. On 1/25/23 at 11:03 AM, V2 (DON/Director of Nursing) said the urinary catheter bag should not be placed on the ground. V2 also said if a resident has a urinary catheter and has a bowel movement, they should be cleaning the urinary catheter tubing. The facility's Perineal Care Policy and Procedure revised on 9/27/21 shows for a female resident to wash perineal area, and if the resident has an indwelling catheter, to gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. The facility's Urinary Catheter Care Policy and Procedure, dated 9/18/19, shows Be sure the catheter tubing and drainage bags are kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 3 of 3