Inspection·July 25, 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, interviews, and record reviews, the facility failed to provide necessary incontinence care in a timely manner on residents who are dependent on staff for performing their activities of daily living. This deficiency affects four (R6, R7, R10 and R11) of four residents reviewed for activities of daily living. Residents Affected - Some Findings include: R7's medical record documents R7 initially admitted in the facility on 12/09/20 with diagnoses of Chronic Obstructive Pulmonary Disease, Unspecified; Parkinson's Disease without Dyskinesia, without mention of fluctuations; Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. MDS (Minimum Data Set) assessment dated [DATE] documented: Section GG - Toileting hygiene: partial/moderate assistance to maintain perineal hygiene. R7's care plan on bowel and bladder incontinence related to cognitive impairment dated 08/31/22 recorded Intervention: Clean peri-area with each incontinence episode. On 07/23/24 at 9:30 AM during incontinence care observation, V7 (Certified Nurse Assistant, CNA) was changing R7's incontinence brief. His brief was observed fully soaked with urine, and the incontinence pad placed underneath was also wet with urine. V7 was asked regarding incontinence care. V7 verbalized, My shift starts 6 AM to 2 PM. He was last changed during night shift. He is supposed to get changed every two hours but when I came in at 6 AM, I got busy, and trays came around 8 AM that we have to distribute. R7 stated that he was changed last night. R6's medical record documents R6 admitted in the facility on 02/15/24 with diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia; Chronic Obstructive Pulmonary Disease, Unspecified; Heart Failure, Unspecified; and Acute Kidney Failure, Unspecified. MDS dated [DATE] indicated that R6 needs substantial/maximal assistance in maintaining perineal hygiene. On 07/23/24 at 9:40 AM, V7 was providing incontinence care on R6. R6 stated, I was last changed like before sleeping last night. This would be the first time that I will get changed this morning. There's stool in there now. I have been calling since 6:30 AM but no one came. R6's brief was fully soaked with urine, with moderate amount of soft bowel movement. Her incontinence pad was also saturated with urine. The flat sheet covering the mattress is wet with urine which extended to her mid upper back. R6's care plan on Bladder incontinence related to physical functioning dated 05/21/24 documented the following: Intervention - Check and change every 2-3 hours and PRN (when needed); Clean peri-area with each incontinence episode. R10's medical record documents R10 admitted in the facility on 02/07/24 with diagnoses of Primary (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 4 Event ID: 145660 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 145660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Westchester 2901 South Wolf Road Westchester, IL 60154 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)