Inspection·January 28, 2025

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 timely incontinence care for one of one resident(R1), reviewed for incontinence care, in a sample of 3. Residents Affected - Few The facility policy, Guidelines for Incontinence Care, dated 9/21/23 documents, It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with daily care. Frequency depends on bladder diary results and/or routine minimal every two-hour checks as well as care planning. R1's facility Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Polyneuropathy, Arthritis, Morbid Obesity, Major Depressive Disorder, Lymphedema and Dementia. R1's most recent Minimum Data Set Assessment, dated 10/11/24 documents that R1 is, always incontinent of bowel and bladder. R1s Care Plan in effect on 1/16/2025 documents, (R1) has a functional bowel and bladder incontinence r/t (related to) Impaired Mobility, Physical limitations, Obesity. Interventions include: Check (R1) every 2/hrs (hours) and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. On 1/27/2025 at 8:15 A.M., V4/R1's daughter stated she came to the facility on 1/16/25 at 11:45 A.M. for a care plan meeting for (R1). V4 further states she went to (R1's) room at approximately 12:15 P.M. and found (R1) lying in a urine saturated bed. V4 states urine was up to (R1's) shoulders, and down to (R1's) knees. V4 states (R1's) gown and all of (R1's) blankets were also urine saturated. (V4) states she put call light on to alert staff, after an unknown amount of time, walked to nurse's station where two nursing employees were seated and voiced concerns with (R1's) need for immediate assistance. The two employees came to room and then V3/Certified Nursing Assistant also came into room and was trying to apologize. V3/CNA states she had come into (R1's) room at 8:00 A.M. to change (R1) before breakfast, but R1 refused the assistance. V3/CNA then stated she had not had time to return to room to provide care for R1, until now. On 1/27/25 at 9:08 A.M., V7/Certified Nursing Assistant stated she frequently works 4100 hall and was present the day of the incident with R1. V7 further states she was one of the staff members who responded to R1's room. States R1 was fully saturated with urine from her shoulders to her knees and all bed linens were also saturated. States she was one of two staff that assisted in giving R1 a shower on that day. Does not recall any pressure wounds present on R1's buttocks on that day. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145269 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 145269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hope Creek Nursing & Rehab 4343 Kennedy Drive East Moline, IL 61244 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)