Inspection·May 31, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide personal care to dependent residents. Residents Affected - Few This applies to 2 of 4 residents (R2, R3) reviewed for activities of daily living care in a sample of 4. Findings Include: 1. R2 is a [AGE] year-old female with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE] and dependent on staff for personal hygiene. On 5/30/24 at 10:10 AM, R2 was observed with V10 (LPN-Licensed Pratical Nurse) in her room. R2 was noted with a strong urine odor. V10 (Licensed Practical Nurse/LPN) checked on R2, and R2 was observed to be dirty and soaked incontinent brief with urine and discoloration (blackish). On 5/30/24 at 10:10 AM, V10 stated, The CNAs are supposed to change residents every two hours. I don't think R2 was changed today, and I will check with my CNA (Certified Nursing Assistant) to change R2. A review of R2's care plan documents that R2's care is planned for the risk of impaired skin integrity, with interventions including Providing skin care per facility guidelines and as needed (PRN). 2. R3 is a [AGE] year-old female with mild cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R3 is dependent on staff for personal hygiene. On 5/30/24 at 10:30 AM, R3 was in her bed and stated, A lot of time, they don't change me on time. I don't remember anybody changed me today. On 5/30/24 at 10:30 AM, V11 (LPN) checked on R3. R3 was observed with incontinent brief, dirty, and heavily soiled urine that was discolored (blackish inside). A review of R3's care plan documents that R3 is care planned for the risk of impaired skin integrity, with interventions including Providing skin care per facility guidelines and as needed (PRN). On 5/30/24 at 11:00 AM, V2, Director of Nursing (DON) stated, Our residents are supposed to get incontinent care every two hours and as needed. The facility presented the Incontinent-Peri Care Policy (Revised March 2020) document: Incontinent (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 05/31/2024 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)