Health inspection·April 25, 2023

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 ensure residents who require extensive assist with activities of daily living received incontinence care and bathing. This applies to 4 of 6 (R1, R3, R4, R6) residents reviewed for activities of daily living in the sample of 6. Residents Affected - Some The findings include: 1. On 4/25/23 at 10:09 AM, R3 was observed lying in bed, his hair was disheveled and unkempt. A strong permeating smell of urine was coming from his room. His incontinent brief was heavily saturated with urine. Urine soaked thru his incontinent pad and his top bed sheet. R3 said the staff forget to change him this morning, and he has not received a shower since he's been at the facility. On 4/25/23 at 10:10 AM, V7 (Certified Nursing Assistant-CNA Agency) said she was called this morning to pick up a shift. She got to the facility between 8:30 AM and 9:00 AM, and is making her rounds to clean residents up. She said R3 was soaked with urine when she entered his room. R3's face sheet shows he is a [AGE] year-old male admitted to the facility on [DATE], with diagnoses including polyneuropathy, hypertension, right foot drop, atrial fibrillation, radiculopathy. R3's care plan, initiated 4/18/23, shows R3 has frequent bowel and bladder incontinence related to immobility with interventions for staff to check R3 for incontinence episodes and he needs assistance to wash, rinse and dry his perineum. R3's care plan shows he has a self-care deficit related to impaired ability and is unable to bathe and groom his self independently. 2. On 4/25/23 at 10:25 AM, R4 was lying in her bed. She said, I need to be changed, I've been waiting since morning. R4 said she put her call light on at 8:30 AM, and told the staff she was soiled and needed to be changed. The staff told me there's no CNA here yet and told me to wait until she comes in. I've been waiting since 8:30 AM (about 2 hours) to get changed, it's terrible. V7 (CNA-Agency) provided incontinence care to R4. R4's incontinent brief was heavily saturated with urine soaked thru the incontinent pad, and stool caked on her bottom. V7 said R4 is soaked with urine, and has dry stool on her bottom. She is making her rounds now to clean up the residents. She was called this morning to pick up a shift and got to the facility between 8:30 AM and 9:00 AM. R4's Minimum Data Set assessment, dated 4/19/23, shows her cognition is intact, requires extensive one person assist with toileting and always incontinent of urine and stool. 3. On 4/25/23 at 9:35 AM, R6 was lying in bed, her hair was stringy and disheveled. She said she does not get her showers as scheduled; it all depends on staffing. I hope I get my shower today. Last Page 1 of 2 145593 145593 04/25/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0677 time I was supposed to get my shower I did not get it. Level of Harm - Minimal harm or potential for actual harm R6's Minimum Data Set assessment, dated 4/14/23, shows her cognition is intact and requires extensive one person assists with bathing. Residents Affected - Some R6's Bathing Report from 3/25/23 to 4/25/23 shows she received two baths in thirty days. 4. On 4/25/23 at 1:24 PM, R1 was observed sitting in her wheelchair in her room. [NAME] visible flakes were observed in her hair. She said sometimes the staff forget my showers. She is supposed to get showers twice a week but gets her showers sporadic. She said she needs staff assistance for bathing. R1's Minimum Data Set assessment, dated 2/17/23, shows she requires extensive assist with bathing. R1's Bathing Report from 3/25/23 to 4/25/23 shows she received six showers in thirty days. On 4/25/23 at 11:55 AM, V5 (CNA) said residents should receive two showers a week, and should be checked and changed every two hours for incontinence care. R1 is alert and oriented and requires staff assist with showers. The facility's Shower and Hygiene Policy revised 7/28/22 states, It is the policy of this facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident . The facility's Incontinent and Perineal Care Policy, revised 7/28/22, states, It is the policy of the facility to promote perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the residents skin condition. Do rounds at least every two hours to check for incontinence during shift . 145593 Page 2 of 2