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 provide timely incontinent care to dependent
residents.
Residents Affected - Some
This applies to 5 of 5 residents (R1-R5) reviewed for activities of daily (ADL) care in a sample of 5.
The Findings Include:
1. R1 was a [AGE] year-old male admitted on [DATE] and having severe cognitive impairment as per the
MDS dated [DATE].
On 8/31/24 at 11:00 AM, V1 (Administrator) stated that she heard about the incident and that the
ambulance people were complaining that R1 was not clean when they picked him up on 8/24/24 to the
hospital.
On 8/31/24 at 12:20 PM, V8 (R1's certified nursing assistant / CNA) stated, I heard that EMS (Emergency
Medical Service) was complaining that R1 was not super clean at the time of pick up at around 1:45 PM on
8/24/24. I didn't see any bowel movement when EMS picked him up, and I was with another resident. He
didn't have a bowel movement for the last 3-4 days.
On 8/31/24 at 11:00 AM, V2 (Assistant Director of Nursing / ADON) stated, I was not here when EMS
picked up R1 on 8/24/24. When they picked him up, I heard that R1 was a big mess with bowel movements.
He ended up having a gastrointestinal (GI) bleed.
2. R2 is an [AGE] year-old female with mild cognitive impairment as per the MDS dated [DATE]. MDS also
documented that R2 is dependent on toileting hygiene and showering/bathing.
On 8/31/24 at 9:55 AM, R2 stated, They didn't change me today. They changed me last night; the girls
might be too busy.
On 8/31/24 at 9:55 AM, as per the writer's request, V3 (Registered Nurse / RN) checked on R2, who was
observed with a urine-soaked brief and an intense urine smell.
On 8/31/24 at 10:00 AM, V4 (Certified Nursing Assistant / CNA) stated, I started my shift at 5:00 AM. I
changed R2 early morning, and I am going to change her now.
A review of the care plan documents that R2 was care planned for functional bladder incontinence,
(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:
145843
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
145843
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Miller Health Care Center
1601 Butterfield Trail
Kankakee, IL 60901
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)
F 0677
with interventions including checking every two hours for incontinence.
Level of Harm - Minimal harm
or potential for actual harm
3. R3 is a [AGE] year-old female with mild cognitive impairment as per the MDS dated [DATE]. MDS also
documents that R3 is dependent on toileting hygiene.
Residents Affected - Some
On 8/31/24 at 10:20 AM, R3 was observed with a urine-soaked brief with mild discoloration (light black).
On 8/31/24 at 10:20 AM, V6, CNA stated that she didn't get a chance to change her.
4. R4 is a [AGE] year-old male with cognition intact as per the MDS dated [DATE]. MDS also documented
that R4 is dependent on toileting hygiene.
On 8/31/24 at 10:05 AM, V10 (R4's wife) stated, R4 was not changed yet. I was giving him a urinal, but still,
he is wet.
On 8/31/24 at 10:05 AM, as per the writer's request, V5, CNA checked on R4 and observed with a
urine-soaked brief.
On 8/31/24 at 10:05 AM, V5 stated, I have two halls, and I haven't changed him yet.
A review of the care plan documented that R4 was care planned for the risk of impaired skin integrity, with
interventions including providing skin care per facility guidelines and as needed (PRN).
5. R5 is a [AGE] year-old male who was readmitted on [DATE]. On 8/31/24 at 10:35 AM, he stated that he
had been changed in the early morning and was wet then.
On 8/31/24 at 10:40 AM, as per the writer's request, V7 (CNA) checked on R5, and R5 was observed with a
soaked brief.
On 8/31/24 at 10:40 AM, V7 stated, I changed him around 8:00 AM. He has a colostomy. I am going to
change him again.
On 8/31/24 at 11:00 AM, V2 added, Residents are supposed to be checked on every two hours for
incontinent care.
The facility presented an incontinence policy approved on 07/2024 document:
Policy: Residents who are incontinent of urine, feces, or both are kept clean, dry, and comfortable while
maintaining their dignity. Residents with an incontinence problem are checked for toileting and changing per
bladder monitoring pattern.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145843
If continuation sheet
Page 2 of 2
