Health inspection·March 8, 2024

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 provide incontinence care and prevent Moisture Associated Skin Damage. This applies to two of four residents (R1 and R2) reviewed for incontinence care. Residents Affected - Few Findings include: 1. R1 was discharged from the facility on 11/05/2023. R1 was admitted to the facility on [DATE] for rehabilitation following a bilateral hip replacement. R1 has diagnoses that includes anemia, morbid obesity, diabetes, urine retention, constipation, anxiety, congestive heart failure, muscle weakness, and a history of falling. R1's MDS (Minimum Data Set), dated 10/05/2023, indicated she was cognitively intact. The admission assessment identified R1 as being dependent on staff for toileting hygiene, showers / bathing, dressing lower body and personal hygiene. R1 was assessed as completely dependent on staff for repositioning. The care plan, dated 9/29/2023, - R1 presented with decreased transfers and ADL (Activities of Daily Living) due to weakness post hospitalization. R1 is admitted with surgical wound to bilateral lower extremities post-surgical repair due to right and left intertrochanteric (hip) fracture. At risk for skin impairment related to required ADL care assist due to recent hospitalization, decreased mobility, history of diabetes and urinary incontinence. Intervention includes encourage / assist with turning / repositioning often. Monitor pressure areas for color, sensation and temperature. Monitor skin status with routine care and notify provider of any changes. R1 physician's orders include cleanse peri area / buttocks with soap and water, pat dry and apply topical cream every shift for prevention. PCT to apply ointment A&D ointment as needed for redness and irritation. On 3/6/2024 at 12:15 PM, V3, Wound Nurse, stated R1 did not have a pressure wound or MASD (Moisture Associated Skin Damage) on admission. V3 stated R1 developed a right buttock and sacral / coccyx MASD that progressed to a stage 2 (partial thickness loss of dermis) pressure wound. V3 stated on 9/29/2023, R1 was identified as being at risk for developing a pressure wound on admission. V3 stated on 10/2/2023, skin barrier and a protective dressing were ordered. On 10/3/2023, off-loading of heels, turn and repositioning was ordered. On 10/5/2023, an air mattress was ordered. V3 stated pressure wounds can develop overnight. V3 stated she did not document any episodes of R1 refusing care. On 3/6/2024 at 4:10 PM, V2, DON (Director of Nursing), stated she knew of R1's facility acquired wounds through discussion. V2 stated she had no knowledge of R1 refusing care. If (R1) had refused care, nursing would document it and report it to therapy and management. On 3/7/2024 at 11:52 AM, V4 (R1's Family Member) stated she stayed overnight at the facility from 9/29/2023 to 10/11/23. V4 stated on the nights she stayed at the facility, staff looked in R1's room, (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 7 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 03/08/2024 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)