Health inspection·August 22, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 apply the correct treatment to a wound for one (R6) of three residents reviewed for wounds in a sample list of seven. Residents Affected - Few Findings include: R6's Care Plan initiated 5/6/2024 includes the following diagnoses: Wedge Compression Fracture of Unspecified Lumbar Vertebra, Alzheimer's Disease, Difficulty In Walking, Symptoms And Signs Involving The Musculoskeletal System, and Protein-Calorie Malnutrition. R6's Pressure Ulcer Risk assessment dated [DATE] documents R6 is at moderate risk for skin breakdown. R6's Wound assessment dated [DATE] documents R6 has a facility acquired stage 4 pressure ulcer to the left buttock. R6's physician's order dated 8/12/24 written by V13 (R6's Physician) documents to cleanse the wound to the left buttock, pat dry, apply calcium alginate, and cover with an abdominal (ABD) pad every day and as needed. The Facility's Medication Administration Policy effective 03/2024 states in section II bullet one: Medications must be administered in accordance with the physician's order. On 8/20/24 at 8:18 AM, there was a hydrocolloid dressing on R6's left buttock. V5 (LPN) removed the hydrocolloid dressing from R6's left buttock. V5 then cleansed the wound, applied calcium alginate to the wound bed and covered with an ABD pad. On 8/20/24 at 8:52 AM, V5 confirmed R6's treatment order for the wound on the left buttocks is to cleanse the wound to the left buttock, pat dry, apply calcium alginate, and cover with an ABD pad every day and as needed. V5 stated that sometimes the ABD pad becomes soiled, and the other nurses often use the hydrocolloid to cover the wound. On 8/21/24 at 12:28 PM, V2 Director of Nursing stated all nurses are expected to follow the physician's orders. 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: 145058 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 145058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Chillicothe 1028 Hillcrest Drive Chillicothe, IL 61523 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)