Health inspection·June 12, 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 timely incontinence care for 2 of 5 residents (R1 and R2) reviewed for activities of daily living. Residents Affected - Few Findings include: 1.R1 is a [AGE] year-old with diagnoses including pressure ulcer sacral region stage 3, diaper dermatitis, moderate protein-calorie malnutrition, irritable bowel syndrome with diarrhea, and anemia. The care plan dated 04/30/2024 showed that R1 has a limited ability to participate in daily care activities and has an impairment of skin integrity related to incontinent care. The admission MDS (Minimum Data Set) assessment, dated 04/10/2024, showed the resident was cognitively intact, and R1 was always incontinent of bladder and bowel and required extensive assistance from staff for incontinent care. During an observation and interview on 06/11/2024 at 11:30 a.m., R1 was lying on her back and was upset and tearful. R1 said she had a bowel movement at 10:00 a.m., and one of the Nursing Assistants said she needed another person's help to change her briefs for bowel incontinence care but never showed up. R1 said when she called for help again, someone came and said someone would be there in 15 minutes, shut off the call light, and no one showed up. R1 further said that the morning staff changed her briefs around 06:00 a.m., and today is the worst day. R1 said she was also waiting for her shower and that at least someone should explain what was happening. R1 used the call bell in Front of the writer, and V4(Registered Nurse) attended R1 and did not ask why she had called her. V4 assumed that R1 had called her about the shower and told R1 that her assigned CNA was providing a shower to another resident and she would come and take R1 after she finished showering another resident. The writer asked V4 why R1 had to wait for one and a half hours for incontinent care, V4 said she attended R1 a few times and explained why she was delayed. R1 became upset and tearful again and said she was disturbed by what V4 said and did not appreciate V4 telling the writer that she had attended to her a few times to explain, which was not true. V5 and V6 (Certified Nursing Assistant-CNA) said they were not assigned to R1 and, attended to R1 after this writer notified them and provided incontinent care. R1 had a moderate bowel movement with dry feces on both sides of the inner thigh, and V5 and V6 acknowledged the observation. 2. R2 is an [AGE] year-old female with diagnoses including bed confinement status, anemia, obesity, malignant neoplasm of breast, h/o cutaneous abscesses of buttocks, blisters of lower back and pelvis, and anxiety. The care plan dated 05/16/2024 showed limited functional abilities to her Activities of daily care and risk for complication. R2 was on diuretic medications and is occasional to frequent incontinent of bladder and bowel with skin breakdown, and has an intervention to keep as clean Page 1 of 2 145614 145614 06/12/2024 Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and dry as possible to minimize skin exposure to moisture by providing incontinent care after each incontinent episode. The MDS (Minimum Data Set) assessment, dated 05/08/2024, indicated the resident was cognitively intact, dependent, and required extensive assistance from staff for incontinent care. During an observation and interview on 06/11/2024 at 12:09 p.m., R2 was lying on her back and responded to this writer's questions about her care. R2 said she was provided incontinent care around 11:00 a.m. during this shift, and before that, her incontinent care was around 04:30 a.m. by the night staff. R2 said she was at least wet for two hours before staff changed her briefs. On 06/11/2024 at 12:25 p.m., V6 (Certified Nursing Assistant) was assigned to R2. She said she had provided care once this morning. R2 is alert and didn't ask her to provide incontinent care or change her briefs. V6 said rounds should be done at least every two hours, and residents should be checked for care needs. During an interview on 06/11/2026 at 11:52 a.m., V3 (Assistant Director of Nursing) said she would talk to the residents and do her investigation. V3 said every resident should be checked at least every two hours, and incontinent care should be provided as needed. On 06/11/2024, at different times, V7, V8 (Certified Nursing Assistants), and V9 (Licensed Practical Nurse) said staff are expected to do regular rounds and provide incontinent care as needed. A review of the grievance binder for the past three months showed that on 03/04/2024, 03/13/2024, 04/01/2024, 04/11/2024, 04/14/2024, and 04/18/2024, residents/family voiced concerns of staff not attending to call lights in a timely manner and delay in providing activities of daily living care. A review of Resident Council meeting minutes for the past three months showed that on 03/27/2024, the call light needing to be answered in a timely manner was one of the concerns. The facility's guideline, with no date, titled Incontinent Care, showed in part that incontinent care is provided to keep residents dry, comfortable and odor-free as possible. The facility's policy, dated 01/2017, titled Prevention of pressure wounds, in part indicated checking residents at least every two hours and cleaning skin when soiled. 145614 Page 2 of 2