Health inspection·February 24, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 that staff provided post-surgical wound care according to current physician's orders for 1 of 3 residents (R2) reviewed for wounds in the sample of 6; and failed to follow their facility policies on following physician orders for surgical wound care. Residents Affected - Few Findings include: R2's face sheet indicated that resident admitted to the facility on [DATE] with a past medical history not limited to: chronic kidney disease, hypertension, convulsions, history of transient ischemic attack and cerebral infarction, major depressive disorder, and open wound to left foot. On 02/22/2025 at 11:37 AM, R2 was observed sitting in his wheelchair in his room wearing a slipper to his right foot, and a thick black sock to his left foot. R2 indicated that he had surgery last week and has a wound to his left foot that is painful at times. R2's Podiatrist Note by V7 (Wound Care Physician) dated 01/22/2025 at 11:42 documented that R2 underwent outpatient surgery today: excision of bone spur [left] first metatarsal. He tolerated the procedure and anesthesia well and will be discharged back to the facility today. Post op wound care orders have been entered into [electronic health record] and sent to (V6) wound nurse. Right foot should be elevated while the patient is at rest in bed. The patient may ambulate as tolerated in his post op surgical shoe and take [pain medication] as ordered for pain. Keep dressing clean dry and intact until first nurse dressing change on 01/27/2025. Call [V7] with any questions. Podiatrist Note by V7 (Wound Care Physician) dated 02/21/2025 at 16:03 documented that R2 was seen and chart reviewed .Upon removal of the silver alginate and bordered gauze dressing to the left foot there is a 2-1/2 cm (centimeter) x 4 cm stage II ulceration deep to subcutaneous tissue at the dorsal aspect of the first metatarsophalangeal joint .Following verbal informed consent I cleansed the wound thoroughly with [antiseptic povidone-iodine] solution. I then performed a thorough lavage with [antiseptic povidone-iodine] 10% solution. Next I applied collagen powder silver alginate wound pad gauze rolled gauze and [self-adherent wrap] with mild compression. I recommend this wound care be repeated every 24 hours until my next follow-up the patient in 5 days .I will also place an order with wound care nurses . On 02/22/2025 at 3:42 PM, V7 (Wound Care Physician) said that R2 has wound issues and delayed healing due to non-compliance with not wearing his surgical shoe, not elevating his leg, and continues to smoke. V7 indicated that R2 continues with antibiotic therapy, will have a doppler study done, and be seen by a vascular team next week. V7 added that R2's wound has slightly improved from 02/12/2025 Page 1 of 3 145173 145173 02/24/2025 Heather Health Care Center 15600 South Honore Street Harvey, IL 60426

F 0684 to when he assessed the wound on 02/21/2025 and he ordered a new daily wound care treatment for R2. Level of Harm - Minimal harm or potential for actual harm On 02/23/2025 at 09:20 AM, V6 (Wound Care Coordinator) performed wound care to R2's left foot. V10 (Wound Care Tech) was also present and removed the soiled dressing. V6 then cleansed the foot wound initially with an antiseptic povidone-iodine solution applied to a gauze pad, then cleansed the wound with normal saline applied to a gauze sponge. V6 then covered the wound with a sheet of silver alginate, applied a thin layer of 2x2 gauze pads over the alginate, then wrapped R2's wound and foot with a gauze bandage roll and secured the end of roll with medical tape. Residents Affected - Few Review of R1's current physician's orders on 02/23/2025 at 10:00 AM showed the following wound care orders: clean left foot wound every 24 hours with [antiseptic povidone-iodine] solution, apply collagen powder, silver alginate, [prescription antibiotic] 2% ointment, gauze and self-adherent wrap or ace bandage for mild compression start date 02/23/2025 0900; apply mupirocin external ointment 2% to left foot wound topically one time a day with silver alginate and collagen powder daily, start date 02/23/2025 09:00; apply [alginate] to left medial foot topically every day shift for wound care, clean with [antiseptic povidone-iodine] solution, apply silver alginate, cover with abdominal pad, wrap with gauze bandage roll, then mild compression with self-adherent wrap or ace bandage and apply to left medial foot topically as needed for soiled/dislodged dressing, start date 2/21/2025 13:00; On 02/23/2025 at 12:00 PM, when asked about the observed wound care to R2's left foot and why it differed from the current physician's orders, V6 (Wound Care Coordinator) said V7 (Wound Care Physician) entered a new wound care order yesterday. After review of R2's active physician's orders with surveyor, V6 said that she followed the wound care order that popped up on the TAR (treatment administration record) and did not see the new order on the treatment record for collagen powder or antibiotic ointment but would have applied them if she would have seen it. At 12:04 PM, V6 (WCC) said that she misread the order, and will call V7 to inform him of what she did, and see if V7 wants her to provide wound care again for R2 to apply the missed medications. V6 (Wound Care Coordinator) added that she will have V7 (Wound Care Physician) clarify R2's wound order moving forward. Review of R2's treatment administration record for February 2025 showed on page 1 the following order: apply 2x2 silver alginate to left medial foot topically every day shift for wound care. Clean with [antiseptic povidone-iodine solution], apply silver alginate, abdominal pad, wrap with [rolled stretch gauze], then mild compression with self-adherent wrap or ace bandage wrap. Order Date-02/21/2025 1300. On 02/23/2025 at 12:10 PM, V6 (Wound Care Coordinator) said that she spoke with V7 (Wound Care Physician) who indicated the treatment did not have to be performed again but to continue with the previous treatment order tomorrow. On 02/23/2025 at 12:54 PM, V2 (Assistant Director of Nursing) said her expectation is for nurses to follow physician orders according to the physician order sheet (POS), orders should be carried out appropriately, and nurses should obtain a physician's order if changes were made to the current order. When asked if not following physician's wound care orders could contribute to a delay in wound healing, V2 (ADON) said yes, and that nurses should be following the direct physician order. 145173 Page 2 of 3 145173 02/24/2025 Heather Health Care Center 15600 South Honore Street Harvey, IL 60426

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility Wound Care (Surgical) policy dated 03/04/2021 reads in part: wound treatment will be performed as per MD (Medical Doctor) orders. Utilize clean/aseptic technique .Undress and expose only one area at a time .Change dressings in order from clean to dirty .Follow MD orders and apply new dressing . Physician's orders for medications and treatments policy dated 06/2022 reads in part: medications will be dispensed and subsequently administered to a resident only upon the clear, complete and signed order of a lawfully authorized prescriber. On 02/24/2025 at 09:45 AM, V1 (Administrator) provided education provided to staff regarding physician's orders for medications or treatments and counseling provided to V6 (Wound Care Coordinator) dated 02/23/2025 for not following physician's orders when providing wound care to resident. 145173 Page 3 of 3