Health inspection·December 10, 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 were changed in a timely manner for 1 of 9 residents (R3) reviewed for Activities of Daily Living (ADL) in the sample of 9. Residents Affected - Few The findings include: On 12/9/24 at 9:43 AM, R3's call light was alarming. R3 said she needs her wet diaper changed and has been wet all morning. R3 said she was last changed in the early morning around 6:00 AM to 7:00 AM. R3 said her call light was answered once and staff said they would be back to change her, but that was over an hour ago and no one has returned. R3 said she feels very wet and staff never check on her. During this conversation, V6 (Licensed Practical Nurse/LPN) came in and said she would return to change her. On 12/9/24 at 9:53 AM, R3 pushed her call light again and at 9:56 AM, someone said, over the intercom, they would be in to change her. V7 (Certified Nursing Assistant/CNA) arrived to change R3 at 9:58 AM. When V7 removed R3's brief, the brief, the disposable pad, and the cloth draw sheet were all soaked with urine. R3's buttocks were red and excoriated. On 12/9/24 at 10:05 AM, V7 (CNA) said she checks on the residents every hour, and changes incontinent residents three times a day, but they are short staffed on CNAs today. On 12/9/24 at 1:33 PM, V2 (Director of Nursing) said incontinence briefs need to be changed when the resident calls to be changed. On 12/10/24 at 9:31 AM, V9 (CNA) said residents need to be changed as soon as possible when they are wet. R3's admission Record dated 12/10/24 shows R3 is an [AGE] year-old female and her diagnoses include, but are not limited to, need for assistance with personal care and lack of coordination. R3's current care plan provided by the facility shows R3 has ADL self-care performance deficits and limitations in physical mobility. R3 requires substantial/maximal assistance with toileting hygiene. R3 is at risk for alteration in skin integrity and has actual impairment of moisture associated skin damage (MASD) to her sacral area and her skin is to be kept clean and dry. The facility's ADLs Policy (dated 5/2018) shows the facility is to ensure resident activities of daily living are being adequately met. 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: 146143 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 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)