Health inspection·February 11, 2025

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, interview, and record review, the facility failed to ensure that staff provide shower/bed bath and grooming as scheduled for residents who are dependent on staff for Activities of Daily Living (ADLs). This failure affected four (R1, R2, R3, and R4) of five residents reviewed for ADL care. Residents Affected - Some Findings include: R1 is an [AGE] year-old female, face sheet listed the following past medical history: Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified severe protein-calorie malnutrition, unspecified symptoms, and signs involving cognitive function and awareness, xerosis cutis, atrophic disorder of skin, other reduced mobility, history of falling, essential primary hypertension, major depressive disorder single episode. 2/11/2025 at 10:20AM, R1 was observed in the dining room sitting in a wheelchair, alert, and oriented x(times) 1 to 2 and stated that she is doing okay, R1 was unable to answer other questions. 2/10/2025 at 1:14PM, V6 (Family member / POA) stated that this has been an ongoing issue with the facility, 2 to 3 times in a week R1 has been left sitting in her urine and feces, she has a pressure ulcer to her bottom and though it is covered with dressing, she is not supposed to be left wet. V6 said that R1 is supposed to get her showers twice a week on Tuesdays and Fridays but that does not happen, family must complain before she gets a shower. 2/11/2025 at 11:19AM, V10 (Family member) came to the facility and confirmed all the concerns shared by V6 to the surveyor. R1 is assessed with a BIMS score of 11(Minimum Date Set) MDS assessment dated [DATE] section C (cognitive pattern). Section GG of the same assessment documented that R1 requires substantial / maximal assistance to partial/moderate assistance from staff for all ADL need. Section H of the same assessment documented that R1 is always incontinent for bowel and bladder., Shower schedule for the second floor showed that R1 is scheduled to get a shower on Tuesday and Friday on first shift, surveyor requested for R1's shower sheet but the facility was able to provide six shower sheets for the year 2024 and one shower sheet dated 2/7/2025 for this year. There is no documentation in resident's medical record that she refused any shower. 2/10/2025 at 12:30AM, V2 (DON) said that residents are scheduled for showers two times a week, there should be two shower sheets per week for each resident, shower sheets are supposed to be completed and signed by the certified nurse assistant (CNA) the nurse and the resident if they are alert. Shower sheets are to be completed even of resident refuses a shower. V2 added that sometimes the (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 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 02/11/2025 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)