Health inspection·March 1, 2024

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 Based on observation, interview and record review, the facility failed to provide incontinent care and provide Activities of Daily Living care to residents. Residents Affected - Some This applies to 8 of 8 residents (R3-R10) reviewed for incontinent care and Activity of Daily Living Care on the sample list of 10. Findings include: 1. On 2/28/24 at 10:57 AM, R3 was sitting up in bed in hospital gown watching TV. R3 said she wears an incontinent brief and needed to be changed. R3 said the last time she was changed was at 5:30 AM (over 5 hours earlier) this morning and she does not know which CNA (Certified Nurse Assistant) was assigned to her. At 10:59 AM, R3 pushed her call light and V5 (Restorative Aide) answered the call light at 11:02 AM. V5 said she does not know who R3's CNA (Certified Nurse Aide) was, but will inform her that R3 needed to be changed. At 11:06 AM, V6 (Restorative Aide) came in to change R3. During R3's incontinent care, it was observed that R3's incontinent brief was soaked with urine to the point the incontinent pad that R3 was laying on was also wet. R3's buttocks were noted with redness and R3 complained of soreness to her buttocks. V6 said that R3 was a heavy wetter and does not know the last time R3 was changed since she was not the aide assigned to her. On 2/28/24 at 12:41 PM, V9 (Rehab CNA) said she was the CNA assigned to R3. She said she has not provided incontinent care to R3 since her shift started at 7:00 AM. V9 said that V5 had completed R3's incontinent care. V5 said she did not provide incontinent care to R3 and V6 was the one that provided incontinent care to R3 earlier. R3's EMR (Electronic Medical Record) shows a diagnosis of overactive bladder. R3's MDS (Minimum Data Set) of 2/12/24 shows that R3's cognition is intact and she is dependent on staff for toileting hygiene. R3's care plan (initiated 2/12/23) shows that R3 has an ADL self-care performance deficit. The facility's Incontinent Peri Care policy (revised March 2020) states incontinent or perineal care shall be provided by nursing staff to all residents identified by staff to be incontinent or needing assistance. Incontinent care can be provided at least every 2 hours and as needed. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs and nursing staff were responsible for incontinent care; incontinent care should be done every 2 hours and as needed. V3 also said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 2. On 2/29/24 at 10:31 AM, R9 was observed in bed watching TV. R9 had a hospital gown on with brown Page 1 of 3 145329 145329 03/01/2024 Norridge Gardens 7001 West Cullom Norridge, IL 60634

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stains on it. R9's hair was not combed or brushed, appeared greasy, skin and hair had dry white flakes falling off. R9 said she did not get a shower yesterday (Wednesday) and one was not offerred. She said staff does not want to give her a shower because she is heavy, and they do not wash her hair. R9 is scheduled for showers on Wednesdays and Saturdays. R9's MDS of 12/14/23 shows that her cognition is intact and is dependent on staff for showers and bathing. R9's care plan (initiated on 7/19/21) shows that R9 has an ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 3. On 2/29/24 at 10:20 AM, R8 was observed sitting in the wheelchair in her room. R8 said she did not get a shower yesterday (Wednesday), and it has been a long time since she's had a shower and she really needs one. R8 began to cry and said that she cannot stand up. R8 stated it is hard for her to stand and she feels like staff are scared to give her a shower because she cannot stand. R8 was scheduled to have a shower on Wednesdays and Saturdays. R8's MDS of 2/5/24 shows that her cognition is intact and she is dependent on staff for showers and bathing. R8's care plan (initiated 2/23/22) shows that she has an ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 4. On 2/29/24 at 10:02 AM, R5 was observed sitting in the wheelchair in the hallway. R5 had brownish stains on his sweatshirt and his hair was not combed or brushed. R5 said he did not get a shower yesterday (Wednesday) and he said he would have liked one, but staff did not offer him a shower. R5 is scheduled for showers on Wednesdays and Saturdays. R5's MDS of 11/27/23 shows that R5 needs partial/moderate assistance with showers and bathing. R5's care plain (initiated 1/31/23) shows that R5 has an ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 5. On 2/29/24 at 9:40 AM, R4 was sitting in a chair in his room, R4 had a t-shirt and pants on and both were stained with a whitish gray substance. R4 said he did not get a shower yesterday (Wednesday) and staff told him he would get it later in the day, but they never came back. R4 said he needed staff assistance with showering. R4 is scheduled to have shower on Wednesdays and Saturdays. R4's MDS of 12/19/23 shows that R4 needs partial/moderate assistance with showers and bathing. R4's care plain (initiated 11/16/23) shows that R4 has an ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 6. On 2/28/24 at 2:45 PM, R6 was in bed in his room resting. R6 said he wanted a shower, but he did not get one. On 2/29/24 at 9:50 AM, R6 was in bed; R6 said staff still did not offer him any shower 145329 Page 2 of 3 145329 03/01/2024 Norridge Gardens 7001 West Cullom Norridge, IL 60634

F 0677 yesterday. R6 showers are scheduled for Wednesdays and Saturdays. Level of Harm - Minimal harm or potential for actual harm R6's MDS of 12/18/23 shows that R6's cognition is intact and is dependent on staff for showers and bathing. R6's care plan (initiated 4/14/22) shows that R6 has and ADL selfcare performance deficit. Residents Affected - Some On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 7. On 2/29/24 at 10:10 AM, R7 was sitting in the wheelchair in the dining room. R7 said she did not get a shower yesterday (Wednesday) and she said she would have liked to have one, but staff did not offer her a shower. R7 was scheduled to have showers on Wednesdays and Saturdays. R7's MDS of 1/19/24 shows that she is dependent on staff for showers and bathing. R7's care plan (initiated 5/12/22) shows that R7 has and ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 8. On 2/29/24 at 10:35 AM, R10 was sitting in the wheelchair in her room watching TV. R10 said she did not get a shower yesterday (Wednesday) and she would have liked to have a shower. R10's showers are scheduled for Wednesdays and Saturdays. R10's MDS of 1/3/24 shows that her cognition is intact and requires substantial/maximal assistances with showers and bathing. R10's care plan (initiated 11/24/21) shows that R10 has an ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. The facility's Shower Bed Bath policy (revised March 2020) states that showers will be given to the resident 2-3 times a week and PRN (as needed). Bed baths can be given 2-3 times a week as needed. 145329 Page 3 of 3