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 (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 3 Event ID: 145329 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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)