Health inspection·October 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 staff failed to ensure residents who required staff assistance with Activities of Daily Living (ADLs) received timely incontinence care for 2 of 4 residents (R2, R1) reviewed for ADLs in the sample of 9. Residents Affected - Few The findings include: 1. R2's care plan dated 9/23/24 showed R2 required staff assistance with toileting and transferring. R2's resident assessment dated [DATE] showed R2 was frequently incontinent of urine and stool. On 10/31/24 at 8:44 AM, R2 was asleep in bed. A strong odor of urine was noted in her room. On 10/31/24 at 9:15 AM, R2 was awake, lying in bed. R2 stated, No one has come in yet this morning. I was last changed (provided incontinence care) late last night. The urine odor remained in R2's room. On 10/31/24 at 9:17 AM, V5 Certified Nursing Assistant (CNA) entered R2's room to provide cares. V5 (CNA) stated she had not toileted or provided incontinence care to R2 yet during her shift. As V5 (CNA) removed R2's incontinence brief, V5 stated, She's pretty wet. R2's brief was saturated with urine. Urine had leaked out of R2's brief, onto her shirt, pants, and bedding. 2. R1's care plan dated 10/22/24 showed R1 required staff assistant with toileting. The care plan showed R1 was frequently incontinent of urine and stool. On 10/31/24 at 8:40 AM, R1 was seated in a wheelchair in her room. R1 wore a gown. A urine odor was noted in her room. R1 stated staff got her up around 8 AM that morning, but did not toilet her or change her incontinence brief. R1 said, I wear a diaper. I think I am wet right now. When R1 was asked why staff didn't change her brief when they got her out of bed, R1 stated, I don't know. R1 denied refusing to be toileted that morning or refusing to have her incontinence brief changed. On 10/31/24 at 9:16 AM, R1 remained seated in her wheelchair, eating breakfast in her room. On 10/31/24 at 10:19 AM, R1 had finished eating breakfast. V6 (CNA) entered R1's room to provide cares. V6 (CNA) transferred R1 to the toilet. R1's incontinence brief was saturated with urine. R1's buttocks were bright pink. Urine had leaked out of R1's brief onto the pad on her wheelchair. V6 (CNA) was asked why R1 was not toileted upon getting her out of bed that morning. V6 stated, She refused this morning. R1 immediately turned to V6 and stated, I most certainly did not! Page 1 of 4 145341 145341 10/31/2024 Encore Village 350 West Schaumburg Road Schaumburg, IL 60194

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/31/24 at 9:59 AM, V7 (Licensed Practical Nurse) stated toileting and/or incontinence care should be provided to residents every two hours and as needed. The facility's Urinary Continence and Incontinence-Assessment and Management policy dated 8/2022 showed, The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence . 145341 Page 2 of 4 145341 10/31/2024 Encore Village 350 West Schaumburg Road Schaumburg, IL 60194

F 0692 Provide enough food/fluids to maintain a resident's health. 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 assist a resident with eating and failed to ensure a nutritional intervention was implemented for a resident with significant weight loss. This failure resulted in R4 sustaining significant weight loss. These failures apply to 1 of 4 residents (R4) reviewed for weight loss in the sample of 9. Residents Affected - Few The findings include: R4's Physician Order Sheet (POS) showed R4 had diagnoses of Alzheimer's Disease (AD), dementia and diabetes. R4's careplan initiated on 11/22/23 showed (R4) is at nutritional risk related to score of 5 (malnourished), inadequate oral intake, significant weight loss, low BMI .confusion, delusions, AD, dementia . With intervention to include: provide nourishments: house shake 8 ounces (oz) BID (Twice a Day) with lunch and dinner. Provide supervision, encouragement/cueing, and necessary assistance at meal time and between meals with food and fluids. R4's weight report showed: 10/2/24-115.8 lbs, 6.2 % weight loss from 9/3/24 123.5 (1 month 6.2% weight loss) 10/17/24- 118 lbs, 13.3% weight loss from 135.9 lbs last 5/2/24. (6 months 13.3% weight loss) 10/10/24-115.8 lbs, 14.8% weight loss from 135.9 lbs last 5/2/24. R4's Nutritional Risk assessment dated [DATE] showed, most recent weight 118.0 pounds (lbs). Weight trend for the last 6 months-weight loss. Significant weight loss x 1/3/6 months. That is most likely related to decreased oral intake past month. Goal for weight maintenance or gradual regain. Added house shake 8 oz to lunch/dinner to increase kcal/proteins intake and prevent further weight loss and promote weight re-gain. On 10/31/24 at 8:30 AM, R4 was in the dining room with her eyes closed. Her breakfast food was in front of her untouched. R4's breakfast consisted of scrambled eggs, pancakes and sausage. Staff were in and out in the dining room. There was no staff assisting or giving cues for R4 to eat. At 8:55 AM, R4 was wheeled out from the dining room and was placed in a table by the nurses station. V9 (Certified Nursing Assistant/CNA) said R4 did not eat her breakfast. R4 only eats a PBJ sandwich which will be served to R4 at lunch. On 10/31/24 at 12:45 PM, R4 was in the dining room for lunch eating her PBJ. There was a cup half full with water. There was no house shake noted with R4's lunch meal. R4's meal card showed- 8 ounces of mighty shake to be provided for lunch and dinner. There was no mighty shake provided to R4. On 10/31/24 at 1 PM, this surveyor clarified with V8 (R4's Nurse-Registered Nurse/RN) if R4 was to receive a mighty shake. V8 said R4 was supposed to get a house shake (mighty shake) provided by the kitchen at lunch due to R4's weight loss. On 10/31/24, V12, V17 and V18 (all Dining room servers) said they were not aware that R4 was 145341 Page 3 of 4 145341 10/31/2024 Encore Village 350 West Schaumburg Road Schaumburg, IL 60194

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supposed to receive shakes from the kitchen for lunch and confirmed none of them served R4's mighty shake for lunch. On 10/31/24 at 1:16 PM, V16 (Dietary Director) said R4's house shakes (mighty shake) was supposed to be provided by the kitchen and nursing documents when the resident takes the house shakes. V16 said the dietary servers did not give R4's shake at lunch. V16 said supplements (house shakes) are important for R4 since R4 already had lost a significant amount of weight. On 10/31/24 at 2:50 PM, V4 (Assistant Director of Nursing) said R4 was just reweighed and R4 continues to loss weight. R4's latest weight was 115 lbs which showed an additional 3 lb weight loss for R4, from 118 lbs (10/17/24) to today (10/31/24.) 145341 Page 4 of 4