Inspection·December 16, 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 interview and record review the facility failed to ensure incontinence care was provided per a resident's request for 1 of 4 residents (R10) reviewed for incontinence care in the sample of 10. Residents Affected - Few The findings include: R10's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include radiculopathy of the sacral and sacrococcygeal region, rash and other nonspecific skin eruption, atherosclerotic heart disease, morbid obesity, major depressive disorder, chronic pain, and candidiasis. R10's facility assessment dated [DATE] showed she has no cognitive impairment. R10's care plan initiated 10/9/19 showed, [R10] displays frequent bladder incontinence related to medication side effects . [R10] will remain free from skin breakdown due to incontinence and brief use through next review . Incontinence: I would like the staff to check me for incontinence episode every two hours and as needed. I would also need assistance to wash, rinse, and dry my perineum . R10's care plan initiated 12/10/19 showed, [R10] requires assistance with ADLs (activities of daily living) (bed mobility, transfers, dressing . personal hygiene .toileting . [R10] will be assisted with ADL's as needed . R10's care plan initiated 11/29/20 showed, [R10] has potential for impairment to skin integrity related to . braden (skin breakdown risk assessment) score of 13 (high risk) . [R10] will be free from any redness, blisters, or discoloration to skin through next review date . [R10] is assisted by staff to keep skin clean and dry . R10's 12/12/23 NP (Nurse Practitioner) visit note showed, . Still has groin/pannus (lower abdominal above the pubis area) rash that is improving but itches at times . Urinary Incontinence: Continue meticulous hygiene . On 12/16/23 at 1:28 PM, V10 was sitting in her wheelchair in her room. R10 said she has difficulty when some of the agency staff are working. R10 said on 12/15/23 she put her call light on due to being incontinent and needing her brief changed. R10 said her call light was not answered until about 10:15 PM when the next shift came in. R10 said she has been having problems with being sore, itchy, and needing creams for her skin due to being in wet incontinence briefs for extended periods of time. On 12/16/23 at 2:15 PM, V6 RN (Registered Nurse) said incontinence briefs should be changed as needed to prevent the resident from experiencing moisture and burning. (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 2 Event ID: 145699 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 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 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)