F0677

G

Failure to Provide Timely Incontinence and ADL Care to Dependent Residents

Chicago, Illinois Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely ADL and incontinence care to residents who were dependent on staff assistance. One resident with diagnoses including lack of coordination, cauda equina syndrome, osteoarthritis, and major depressive disorder was cognitively intact and care planned as dependent for toileting hygiene and bed mobility. On the morning in question, this resident reported having a bowel movement after breakfast and stated they had just turned on the call light. A strong fecal odor was noted in the room. Despite the call light sounding, the assigned LPN remained at the medication cart nearby and a CNA walked past the room multiple times over a 14‑minute period without entering.

The resident’s assigned CNA had been sent out of the facility around 8:30 a.m. to accompany another resident to a medical appointment, and coverage was to be provided by other CNAs on the unit. At 10:00 a.m., a covering CNA entered the resident’s room only to turn off the call light and then left without providing care. When the surveyor re-entered the room at 10:15 a.m., the resident was crying and reported that the CNA had said they were busy and would return in a few minutes, which did not occur. Continuous surveillance from 9:00 a.m. to 11:50 a.m. showed that the CNA did not return. The resident reactivated the call light at 11:45 a.m., and another CNA responded at 11:50 a.m., returning with supplies and initiating incontinence care around noon, resulting in the resident remaining soiled with feces for approximately three hours while reporting itching, burning, pain, humiliation, and feeling “like a dog” lying in feces.

A second resident, with medical conditions including spinal stenosis, weakness, a gastrostomy, a sacral pressure ulcer, and polyosteoarthritis, was moderately cognitively impaired and care planned as dependent for toileting hygiene and bed mobility. During the same surveillance period, this resident was heard calling out for help and reported being wet for a long time. The surveyor activated the call light, which the LPN answered by entering the room, turning off the call light, and then leaving to return to the nursing station. The LPN later stated that the resident needed to be cleaned up and that she had told one of the aides but did not recall which one, noting she was occupied with an admission. The resident remained wet until a CNA who had been out on a medical escort returned to the unit and, at the surveyor’s request, provided incontinence care, resulting in the resident being left wet for approximately two hours. Staff interviews referenced ongoing staffing issues and working short, with only two CNAs on the floor for about forty residents and the reassignment of a primary CNA to an outside appointment.