Inspection·October 21, 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 observation, interview, and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for four of four residents (R1, R2, R3, R4) reviewed for ADL care. Residents Affected - Few Findings include: On 10.21.2023 at 11:33 AM, R1 was observed awake, alert, lying in bed. R1 said he was soiled. 1) R1's medical record (Face Sheet) documents R1 is a [AGE] year-old admitted to the facility on 2.20.2020 with diagnoses including but not limited to: Parkinson's Disease, Venous Insufficiency (Chronic) (Peripheral), Acute Kidney Failure, and Weakness. R1's MDS (Minimum Data Set of 7.23.2023) documents R1 is cognitively intact, requires extensive assistance/two + persons physical assist with bed mobility, transfers, and toilet use; R1 is frequently incontinent of urine and stool. 10.21.2023 at 11:33 AM, R1 was observed sitting up in bed. A blue brief was observed sticking out from the top of R1's yellow brief. R1 said staff double diapered him (on the night shift). R1 said, I don't like it. They do that so that they don't have to change me so much. It's my fault because I wet so much. R1 appeared sad (sad facial expression) as he told the Surveyor about the double diapering. At 11:37 AM, V5 (Agency CNA-Certified Nursing Assistant) entered R1's room to provide incontinent care. R1's blue brief and back of R1's yellow brief were saturated with urine; a pungent odor was noted. R1's draw sheet was saturated with urine; a dark ring was noted on R1's fitted sheet. 2) R2's medical record (Face Sheet) documents R2 is a [AGE] year-old admitted to the facility on 1.16.2020 with diagnoses including but not limited to: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus with Hyperglycemia, Chronic Diastolic (Congestive) Heart Failure, and Hyperlipidemia, Unspecified. R2's MDS (Minimum Data Set of 7.11.2023) documents R2 is severely cognitively impaired, requires extensive assistance/two+ persons physical assist with bed mobility, total dependence/two+ persons physical assist with transfers and toilet use; R2 is always incontinent of urine and stool. 10.21.2023 at 10:38 AM, R2 is sitting up in bed with eyes closed, non-verbal. V4 said this is the first time I'm seeing him (to provide incontinent care); I did feed him earlier. V4 lowered the head of R2's bed and undid his brief. Surveyor observed a blue brief (with flaps removed) inside R2's outer brief. R2's blue brief was saturated with urine, the back of R2's yellow brief was saturated with urine. V4 said the line down the front of R2's yellow brief will change color when the resident is wet, however because R2 was double diapered (blue brief inside of yellow brief) the line on the outer brief will not change color even though resident is wet. (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 4 Event ID: 145767 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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)