Health inspection·June 6, 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 to ensure residents received timely assistance with incontinence care. This applies to 4 of 4 residents (R1, R2, R3, R4) reviewed for incontinence in the sample of 4. Residents Affected - Some The findings include: 1. On June 6, 2023, at 9:39 AM, R1 was observed laying in bed in a fetal position. A urine odor was present in the room. Surveyor observed a blue line on R1's incontinence brief, indicating the brief was soiled/wet. On June 6, 2023, at 10:09 AM, V4 (CNA-Certified Nursing Assistant) was observed walking in and out of R1's room without providing care to R1. On June 6, 2023, at 10:34 AM, surveyor observed V4 walk into R1's room to provide incontinence care. V4 stated she started her shift at 6:30 AM. I did my resident rounds at 6:45 AM and changed [R1] at that time. I have not changed her incontinence brief since that time. She is a heavy wetter. The quilted pad underneath R1 had a dried, circular stain, yellow to brownish in color, approximately three feet in diameter under and around R1. A heavy urine odor was present as R1 was turned from side to side. V4 turned R1 to her side and removed her incontinence brief. The brief was soaked with urine, and a loud thud was heard as V4 dropped the soaked brief into the trash receptacle at R1's bedside. R1's buttocks appeared reddened, with three small open areas noted on R1's coccyx. V4 did not apply barrier cream to R1's buttocks and placed a new incontinence brief. V4 did not change the soiled quilted pad underneath R1 after applying a new incontinence brief. V4 covered R1 with a blanket and left the room. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, nontraumatic intracerebral hemorrhage, cellulitis of abdominal wall, aphasia, dysphagia, hemiplegia, and hemiparesis following cerebral infarction, difficulty walking, lack of coordination, weakness, presence of a cerebrospinal fluid drainage device, cerebral aneurysm, color cancer, and obstructive hydrocephalus. R1's MDS (Minimum Data Set) dated February 20, 2023, shows R1 has independent cognitive skills for daily living, is totally dependent on facility staff for transfers between surfaces, toilet use, and bathing. R1 is always incontinent of bowel and bladder. R1's care plan, initiated February 27, 2023, shows R1 experiences bladder and bowel incontinence related to decreased mobility, subarachnoid intracranial hemorrhage. The goal of R1's care plan is to (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: 145901 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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)