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. Page 1 of 3 145700 145700 09/23/2024 Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 prevent a new pressure ulcer from developing for a resident who was assessed to be at risk for developing pressure ulcers while in the facility. This failure applied to one (R1) of three residents reviewed for pressure ulcers. 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 (8/8/24) notes that R1 is dependent on staff for activities of daily living that include turning, repositioning and incontinence care. According to wound care nurse practitioner's progress notes on 8/9/24 R1 was assessed with a wound of the sacrum that measured in centimeters length x width x depth: 2 cm x 3 cm x 1 cm. On 9/11/24 the wound care nurses documented new skin alterations that included Gluteal Cleft tear and Right ischium (skin tear) which did not include measurements. On 9/13/24, the nurse practitioner reclassified these new alterations to be a pressure ulcer stage II measuring 3cm x 1cm x 0.1 cm and the existing sacral wound 1.5cm x 0.5cm x 0.5 cm, indicating that the sacral wound was healing with existing treatments in place. On 9/19/24 at 3:16pm V2 Director of Nursing stated that according to the documentation, R1 was assessed with a gluteal cleft tear and a sacral pressure ulcer that progressed to stage II pressure ulcers. The skin tear was first noted by the wound care team during rounds. V2 stated it is the expectation of the CNA (certified nursing assistant) to notify the nurse of any skin changes, as they should be turning and repositioning and checking for incontinence minimally every two hours. V2 stated the worsening of the wounds could have been potentially caused by decline in nutrition, lack of turning or repositioning or an ineffective treatment plan. V2 stated to their knowledge, R1 did not have any nutritional concerns. Physician orders placed by wound care nurse are as follows: 9/11/2024 13:15 RIGHT ISCHIUM Cleanse with normal saline Pat Dry Apply wound paste everyday shift for Skin Tear and as needed for Skin Tear. 9/11/2024 13:15 GLUTEAL CLEFT Cleanse with normal saline Apply Collagen Cover with Hydrocolloid every day shift every Mon, Wed, Fri for Tear AND as needed for If off or soiled. Care plan initiated 8/27/24 states [R1] will not develop additional skin breakdown. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Skin Care Regimen and treatment Formulary revised 1/24 states in part; Prevention- incontinent/moisture barrier cream every shift and as needed. Treatment Protocol: Skin Tears/Laceration- Film dressing, foam dressing, petroleum gauze and topical antibiotic unless contraindicated. 145700 Page 2 of 3 145700 09/23/2024 Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to replace a damaged call light cord in a resident's room. This failure applied to one (R2) of three residents reviewed for accidents and hazards. Residents Affected - Few Findings include: R2 admitted to the facility 8/30/24 with diagnoses that included femur fracture, cognitive communication deficit, and generalized weakness. R2 discharged from the facility 9/7/24. On 9/18/24 at 10:55am family member of R2 informed the surveyor of a damaged call light with exposed wires in R2's former room. On 9/19/24 at 12:30pm, the call light in R2's former room was observed to be damaged and had been taped ineffectively covering the exposed wires. During the observation, V9 Guest Services entered the room as requested. When V9 saw the damaged cord, V9 removed it and said that they would replace it immediately. Later at 2:04pm, V1 Administrator stated, although the cord did appear to have some damage, it was functional, however it was replaced immediately after bringing it to our attention. Policy titled Hazards revised 7/24 states in part; Policy Statement: It is the facility's policy to ensure the safety of each resident in the building and remove hazardous items and correct situation to prevent accidents. 145700 Page 3 of 3