Health inspection·September 23, 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 interview and record review the facility failed to document incontinence care every shift per facility policy. This failure applied to two (R1 and R2) of three residents reviewed for incontinence care. Residents Affected - Few Findings include: R1 is a [AGE] year-old female who admitted to the facility 8/6/24 with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction and one pressure ulcer of the sacrum stage I. Minimum data set (MDS) assessed 8/8/24 indicates that R1 is dependent on staff for incontinence of bowel and bladder function. R2 admitted to the facility 8/30/24 with diagnoses that included femur fracture, cognitive communication deficit, and generalized weakness. MDS (9/2/24) notes that R2 is dependent on nursing staff for mobility and incontinence care. On 9/18/24 at 10:55am family member of R2 voiced concerns that R2 did not receive overnight incontinence care which led to R2 being soaked in urine when they arrived to visit in the morning. A 30-day lookback was reviewed for R1 and R2 for bowel and bladder function. Point of care (POC) tasks as carried out by CNA (Certified Nursing Assistants) lack documentation that R1 and R2 received incontinence care at least once per shift every day. On 9/18/24 at 10:55am a family member for R1 stated that on 9/11/24 around 10am, they came to the facility and R1 was left soaking in a disposable brief. The family member said after asking for assistance, R1 did not receive incontinence care for over an hour. POC (charting documentation) for 9/11/24 documents only one occurrence of incontinence care for the day, which was documented at 1:27pm. On 9/19/24 at 3:16pm V2 Director of Nursing stated the CNAs (Certified Nursing Assistants) are expected to document in the electronic health record for incontinence care or toileting at least once every shift. Incontinent and Perineal Care Policy revised 7/24 states in part; It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation and to observe the resident's skin condition. Do rounds at least every 2 hours to check for incontinence during shift. 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 3 Event ID: 145700 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 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)