Inspection·July 19, 2023

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 interview and record review, the facility failed to assess, treat and monitor a skin alteration of a newly admitted resident. The facility also failed to document these skin alterations on the discharge orders and summary. This applies to one of four residents (R1) reviewed for pressure sores on the sample list of four. Residents Affected - Few The findings include: R1, a [AGE] year-old female admitted to the facility from hospital on 1/1/2023. R1's diagnoses included but not limited to strain of muscle fascia, tendon of left hips, injury to the head, repeated falls, muscle weakness, difficulty walking, bilateral osteoarthritis of hip, hyperlipidemia, dementia with psychotic disturbance, psychosis, major depressive disorder, and vascular dementia. R1 was residing from assisted living facility prior to being hospitalized , then was admitted to the facility for deconditioning. R1 was discharged on 1/17/2023 and was back to the assisted living facility on 1/17/2023. The MDS (Minimum Data Set) dated 1/15/2023 shows that R1's cognition was severely impaired and required extensive assistance with ADL (Activities of Daily Living) along with mobility and transfer. The MDS shows that R1 was not identified with pressure ulcer but was identified as risk for pressure sore development. The admission assessment dated [DATE] shows that R1 was identified with skin impairments that included bruising on left arm from history of recent falls, and unopened redness on sacrum. The admission assessment did not include a comprehensive assessment of the redness on R1's sacral area. Review of the EHR (Electronic Health Record) shows that there was no follow up to assesses the redness to R1's sacrum The EHR was reviewed with V1 (Administrator) and V4 (Wound Care Nurse) on 7/17/2023 at 2:30 P.M and they confirmed the lack of assessment to the sacral area. V1 and V4 added that the sacral area should have been comprehensively assess and monitored to ensure correct treatment was provided. Review of the ETAR (Electronic Treatment Administration Record) for the month of January 2023 shows that there was a checkmark that R1 skin was check during shower days which was Mondays and Thursdays. There was no documentation of the result of the skin check to show the condition of R1's skin. On 7/18/2023 from 10:37 P.M. to 2:30 P.M. at an intermittent time; the following staff V9, V10, V11 (Licensed Practical Nurses/LPNs) and V12, V13 (Certified Nurse assistants/CNA) were interviewed. They said that the hall has mostly taken care of R1 while R1 was at their facility. They all said that (continued on next page) 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: 145219 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 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)