Health inspection·July 11, 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 observations, interviews, and record reviews, the facility failed to ensure that residents who are dependent on staff assistance for toileting receive the care needed. This failure applies to 1 (R2) of 3 residents reviewed for improper nursing care. Residents Affected - Few The findings include: On 07/09/24 at 11:26 AM, observed R2 sitting in a wheelchair in the unit dining room with other residents. R2 stated R2 was admitted to the facility this past Friday, 07/05/24. R2 stated R2 cannot use the bathroom because R2 cannot bear weight on R2's leg so R2 uses incontinence briefs. R2 stated R2 knows when R2 is wet or soiled. R2 stated, I'm wet right now and I've been wet for a couple of hours now R2 stated the last time R2 was changed was around 6:45-7:00 AM this morning and that no one had asked R2 since then if R2 was wet or needed to be changed. On 07/09/24 at 11:43 AM, V6 (Certified Nursing Assistant) stated V6 has been a CNA for four years and has been working at the facility since November 2023. V6 stated V6 checks on V6's residents every 20 minutes and that V6 is taking care of R2 today. V6 stated V6 gave R2 a bed bath and changed R2 around 7:00 AM this morning. V6 stated since then V6 has not checked with R2 to see if R2 required a change because R2 was in the unit dining room and V6 was busy taking care of V6's other residents. V6 stated V6 has not seen R2 since around 7:00 AM to see if R2 needed to be changed. On 07/09/24 at 11:49 AM, surveyor told V6 that R2 is self-reporting that R2 is wet and needs to be changed. On 07/09/24 at 11:50 AM, observed V6 take R2 to R2's room to change R2's incontinence brief. Surveyor heard V6 ask R2 did any staff check on you when you were in the dining room to see if you needed to be changed? and R2 replied, no, no one asked me. V6 stated someone should have asked R2 if R2 needed to be changed and R2 is alert and orientated so R2 knows when R2 is wet or not. On 07/09/24 at 11:59 AM, after V6 provided incontinent care was provided V6 showed surveyor R2's soiled incontinent brief and stated, that's a good amount of urine. Surveyor observed R2's soiled incontinent brief to be saturated with dark yellow colored urine covering a large area of the brief. V6 stated we don't want her (R2) sitting in her (R2) urine because this could cause a skin breakdown especially if she (R2) is sitting up in a wheelchair for long periods because of all that pressure in that one area. On 07/10/24 at 3:15 PM, V2 (Director of Nursing/Registered Nurse) stated that between the nurse and the CNA rounding on the residents is done every hour and incontinence care should be provided when Page 1 of 2 145983 145983 07/11/2024 Aliya on 87th 2940 West 87th Street Chicago, IL 60652

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the staff is doing their hourly rounds. V2 stated it is important to provide incontinence care when the resident needs it because it could help to prevent a fall, and/or wound development. V2 stated if a resident is wet, they may try to make a move to go to the bathroom which could potentially lead to a fall and if a resident is wet for an extended period of time, it could cause skin irritation which could develop into a skin breakdown. V2 stated if a resident was last changed at 7 AM then the CNA should recheck on that resident at least by 9AM and then again at 11AM. V2 stated even if a CNA's resident is sitting in the dining room all morning for activity functions it is still that CNA assigned to that resident responsibility to round on their residents and check to see if they need to be provided with incontinence care. R2's diagnosis includes but not limited to Polyneuropathy, Monoplegia Of Lower Limb, Fracture Of Upper End Of Left Radius, Subsequent Encounter For Closed Fracture, Unspecified Fall, Need For Assistance With Personal Care, Limitation Of Activities, Unsteadiness On Feet, Reduced Mobility, Cognitive Communication Deficit, Limitation of Activities Due To Disability, Type 2 Diabetes Mellitus. R2's Minimum Data Set (MDS) dated [DATE] documented that R2 is dependent for toileting and substantial/maximal assistance with toilet transfer. R2's Brief Interview for Mental Status (BIMS) not completed yet. R2 was admitted to the facility on [DATE]. R2's Braden Score is 16 (At Risk) dated 07/06/24 listing additional risk factors to include R32 has a scar over bony prominence. R2's Daily Skilled Nursing Noted dated 07/06/24 documented in part, R2 has urinary and bowel incontinence, and needs assistance with toileting. R2's care plan documents in part, R2 is at risk for injury from falls (related to) weakness. Goals include that the facility will reduce the likelihood of the resident experiencing a fall through next review and interventions include but not limited to toilet resident in a timely manner dated 07/07/24. Facility provided policy titled, Incontinence Care dated 1/2024 which documents in part incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. Facility provide policy titled, Activities of Daily Living dated 05/2024 which documents in part, a program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. 145983 Page 2 of 2