Health inspection·January 4, 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 have interventions in place to prevent a pressure injury for 1 of 4 residents (R57) reviewed for pressure injuries in the sample of 17. Residents Affected - Few The findings include: R57's January 2024 order summary sheet documents he was admitted to the facility on [DATE] with multiple diagnoses including hypertension, gout, muscle weakness, and need for assistance with personal care. R57's nursing progress notes of 12/22/23 document he was on droplet isolation precautions and all meals, cares and therapies were provided in his room. R57 refused to get out of bed even after several attempts were made. The notes show on 12/26/23 a 6.35 cm oval area on his left heel that is hard, purple/black in color from pressure on his mattress. The 12/26/23 weekly wound observation tool documents a facility acquired SDTI (Suspected Deep Tissue Injury) to the left heel. The tissue was necrotic (brown, black, leather, scab-like). The wound measured 4 cm in length by 6 cm wide and a depth of 0.1 cm. The 7/19/22 care plan was revised on 12/26/23 and shows R57 is at risk for impaired skin integrity and pressure ulcer development related to very limited mobility requiring extensive assist with all ADL's (Activities of Daily Living) and total dependence for transfers. The 12/15/23 quarterly facility assessment shows he required substantial/maximal assistance to roll left and right and return to lying on his back on the bed. On 1/4/24 at 9:01 AM, V5 (Certified Nursing Assistant/CNA) said R57 is a mechanical lift transfer, he used to stand and transfer but after he was sick, he had a decline. V5 said the staff have to reposition him every 2 hours. He is unable to move himself in bed, he will stay in the same position if not moved. We have to put pillows under his heels, and boots for protection. On 1/4/24 at 9:09 AM, V3 (Wound nurse/Licensed Practical Nurse) said R57 has a deep tissue injury to his heel. She said he was really sick with influenza and had a lot of edema in his feet. While sick, he was in bed more, and assumes that is how he acquired the wound. V3 said R57 was not able to move himself around in the bed and had an overall decline. He should have had his heels floated when in bed, and he did not have the boots, or other interventions in place until after the wound was identified. On 1/4/24 at 10:33 AM, R57's left heel appears to be swollen, dry and purple/black in color. He has Page 1 of 3 145200 145200 01/04/2024 Franklin Grove Living and Rehab 502 North State Street Franklin Grove, IL 61031

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few knee high compression socks on with tennis shoes. He was sitting in a recliner with his feet elevated. A mechanical lift sling was observed under him. The facility's 7/28/23 pressure ulcer/pressure injury policy documents 1. Prevention measures are assessed upon admission, any significant changes and at least quarterly based on the resident risk assessment. Implementation of preventative measure are based on the factors specific to each resident. 145200 Page 2 of 3 145200 01/04/2024 Franklin Grove Living and Rehab 502 North State Street Franklin Grove, IL 61031

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure quarterly smoking assessments were completed for 1 of 2 residents (R32) reviewed for smoking safety in the sample of 17. The findings include: R32's admission Record, provided by the facility on 1/4/24, showed he was admitted to the facility on [DATE] with diagnoses including paraplegia (an impairment in motor or sensory function of the lower extremities), chronic obstructive pulmonary disease with acute exacerbation, muscle weakness, gastro-esophageal reflux disease, major depressive disorder, and idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions. The nerve damage affects the messages sent between the brain and other organs, and areas of the autonomic nervous system, including the heart, blood vessels and sweat glands). R32's Order Summary Report, provided by the facility on 1/4/24, showed the following order: May smoke at specified smoking times. The report showed the order was still active. R32's facility assessment dated [DATE] showed he has a traumatic spinal cord injury and uses a manual wheelchair. R32's smoking care plan, with a revision date of 4/20/23, showed the following interventions Allow (R32) to smoke in designated areas only. Repeated reminders of safety hazards. While smoking, will have supervision by staff. R32's ADL (activities of daily living) care plan, with a revision date of 4/20/23, showed he requires assistance from one staff member for bed mobility, dressing, personal hygiene, toileting, and transfers. The Smoker's List provided by the facility showed R32 was listed as one of the residents in the facility that smoke. On 1/3/24 at 1:05 PM, R32 was outside smoking in the designated smoking area with another resident and a staff member present. A review of R32's electronic medical record on 1/3/24, showed the last smoking assessment for R32 was on 4/10/23. The assessment showed R32 was safe to smoke with supervision. On 1/4/24, all of R32's smoking assessments were requested. The facility provided smoking assessments dated 3/27/19; 4/3/23; 4/10/23; and 1/4/24 (the day the assessments were requested). On 1/4/24 at 1:58 PM, V6 (Regional Nurse Consultant) said the smoking assessments for R32 were not completed quarterly as scheduled. The facility's Smoking Policy, with a review date of 7/25/23, showed b. Residents will be evaluated upon admission, quarterly or more frequently as dictated by any significant changes in condition to ensure that they continue to be capable of smoking and using smoking materials without presenting a danger to themselves or others. 145200 Page 3 of 3