Health inspection·April 18, 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 observations, interviews, and record reviews the facility failed to follow their policy and procedures for activities of daily living by not ensuring a resident received assistance with feeding and personal hygiene as required, and by not ensuring residents who require incontinence care were changed in a timely manner. This failure applies to three of four residents (R93, R121, and R135) reviewed for ADL (Activities of Daily Living) care. Residents Affected - Few Findings include: 1. R93 is a [AGE] year-old female with a diagnoses history of Partial Paralysis Due to Stroke who was admitted to the facility 08/27/2020. On 04/15/24 at 11:33 AM Observed R93 lying in her bed with a towel on her chest. Observed food residue and particles left on R93's mouth and towel on her chest. R93 nodded yes when asked if she fed herself. R93's current Care Plan Initiated: 09/03/2020 documents she has an ADL (Activities of Daily Living) Self Care Performance Deficit and Impaired Mobility related to diagnoses and past medical history of Morbid obesity, hypertension, and stroke with interventions including: requiring total staff participation to eat; and requires 2 staff participation with personal hygiene. On 04/17/24 at 12:24 PM V2 (Director of Nursing) stated, if R93 was fed by staff on 04/15/2024 staff should have cleaned her up. V2 stated, if R93 fed herself and staff collected her tray they should have cleaned her up. V2 stated, if the nursing staff leaves R93 unclean it is a dignity issue. 2. R121 is a [AGE] year-old female with a diagnoses history of Partial Paralysis due to Stroke who was admitted to the facility 10/14/2022. On 04/15/24 at 11:35 AM R121 gestured that she needed her adult brief changed and pulled on her diaper. Observed most of the bottom of R121's foot resting near her adult brief was smeared with feces. V11 (Certified Nursing Assistant) stated, she last changed R121 at 7AM when she started her shift. R121's current care plan Initiated 10/14/2022 documents she requires assistance with ADL's (Activities of Daily Living) including bed mobility, transfers, dressing, walking, personal hygiene, and toileting; R121 displays bowel and bladder incontinence related to medication side effect, decreased mobility with interventions including: Nursing staff to check R121 for incontinence episode every 2 (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 6 Event ID: 145667 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 145667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Park Ridge 1601 North Western Avenue Park Ridge, IL 60068 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)