Inspection·September 13, 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 follow their policy and provide transfer assistance to two dependent residents (R1, R3) out of three residents reviewed for Activities of Daily Living (ADL). Residents Affected - Few Findings include: 1. R1's face sheet documents in part medical diagnoses of paraplegia. R1's comprehensive care plan contains a focus last revised on 11/30/2022. It documents R1 has an ADL self-care performance deficit related to impaired balance, limited mobility, limited range of motion, pain, history of stroke, paraplegia, wounds to feet, and stiffness in the left hand. Intervention initiated on 9/28/2021 documents: TRANSFER: The resident requires 1-2 staff assistance to move between surfaces and as necessary. A focus last revised on 2/26/2023 documents R1 has limited physical mobility related to weakness to upper and lower extremities, both shoulders, wounds on leg, and paraplegia. R1 uses a motorized wheelchair for mobility support and needs assistance with ADL/mobility task. Intervention initiated 9/29/2021 document: Provide supportive care, assistance with mobility as needed. Document assistance as needed. R1's most recent Minimum Data Assessment (MDS), dated [DATE], documents R1 is cognitively intact. It also documents R1 is totally dependent with two plus person physical assist. On 9/12/2023 at 11:22 AM, R1 was lying in bed. R1 was alert and oriented to person, place, and time. R1 stated staff are not assisting R1get out of bed. Last time R1 was out of bed was months ago. R1 stated V2 (Director of Nursing) posted a note on the wall telling staff when R1 is supposed to get out of bed. Note taped to the wall near the window documents, (R1's) Get Up Schedule for Mondays, Wednesdays, Fridays, and Saturdays during morning shifts. R1 stated staff did not get R1 out of bed yesterday (Monday). R1 stated staff was supposed to get R1 up out of bed after lunch, and put R1 back in bed before dinner, but it did not happen. Reviewed R1's progress notes. No notes pertaining to why R1 did not get out of bed on 9/11/2023 (Monday), 9/9/2023 (Saturday), or 9/8/2023 (Friday). 2. R3's face sheet documents medical diagnoses of lack of coordination, abnormal posture, and weakness. R3's comprehensive care plan contains a focus last revised on 7/19/2023. It documents R3 has limited physical mobility related to weakness. Intervention initiated on 7/19/2023 documents R3 requires (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 9 Event ID: 145659 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 145659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford Care Center, The 7445 North Sheridan Road Chicago, IL 60626 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)