Health inspection·October 24, 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 observation, interview, and record review the facility failed to ensure residents received timely assistance with toileting and showers for 2 (R1 and R4) of 4 residents reviewed for Activities of Daily Living (ADL's) in the sample of 10. Residents Affected - Few Findings Include: 1. R4's admission Record with a print date of 10/23/24 documents R4 was admitted to the facility on [DATE] with diagnoses that include sepsis, polyosteoarthritis, malignant neoplasm, dysthymic disorder, hypertension, heart disease, atrial fibrillation, syncope and collapse. R4's MDS (Minimum Data Set) dated 10/16/24 documents a BIMS (Brief Interview for Mental Status) score of 13 which indicates R4 is cognitively intact. This same MDS documents R4 requires substantial/maximal assistance with toilet transfer and moving from a sitting to standing position. R4's current Care Plan documents a Focus Area of I have an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) NSTEMI (non-ST elevation myocardial infarction), poly osteoarthritis, obesity, depression, AIB (abnormal illness behavior), heart disease. Date Initiated: 02/28/24 The interventions documented for this Focus Area include; If resident resists with ADL's, reassure resident, leave and return 5-10 minutes later and try again. Date Initiated: 02/28/2024 .Toilet hygiene: My usual performance is partial/moderate assistance. Date Initiated: 02/28/2024 Toilet transfer: My usual performance is substantial/maximal assistance. Date Initiated: 02/28/2024 . This same Care Plan documents a Focus Area of I am frequently incontinent of bladder .Date Initiated: 03/03/2024 The interventions documented for this Focus area include, Check and change Q (every) 2-3 H (hours) and PRN (as needed). Date Initiated: 03/03/2024 On 10/21/24 at 10:45 AM, R4 was sitting in a recliner covered with a blanket and there was an odor of urine noted by this surveyor. R4 stated she sleeps in her recliner. R4 stated she was sitting in wet clothes and had been since she got up that morning. R4 stated she couldn't remember what time, but V3 (Certified Nursing Assistant/CNA) came in and turned the call light off. R4 stated she couldn't go to the bathroom by herself and no one had helped her up yet this morning. R4 stated she wears a brief for incontinence. On 10/21/24 at 10:49 AM, V3 (CNA) stated she was the CNA providing care to R4 today. V3 stated she had not assisted R4 with toileting since she came on duty at 6:00 AM. V4 stated she turned the call light off in R4's room around 10:30 AM, the floor had been mopped and was wet and she told R4 she would come back after the floor dried. V3 stated R4 normally tells staff when she had to go to 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 2 Event ID: 145918 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 145918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417 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)