Health inspection·February 21, 2025

F 0686 Level of Harm - Actual harm Residents Affected - Few with measurements of 3.00cm x 2.00cm x unknown. Wound assessment detail report dated 02/11/2025 documented the same assessment, indicated R1's wound was facility-acquired and that R1 was provided with cushions to alleviate the pressure. Review of nurse's note dated 02/04/2025 documented a fax was received back from V11 (Primary Care Physician/Medical Director) related to wound stating, local wound care. No documentation found that indicated R1 was seen by a wound physician. R1' s wound round assessment dated [DATE] documented stage 3 pressure ulceration to R1's right ear with measurements of 1.00cm x 1.00cm x 0.20cm. Wound assessment detail report dated 02/17/2025 documented the same assessment, indicated R1's wound was facility-acquired and a new wound assessed, new ear protectors added. Review of repeat pressure ulcer risk assessment dated [DATE] continued to show that R1 is at moderate risk for developing pressure injuries. No repeat skin risk assessment was completed after identifying the second pressure injury to the right ear on 02/17/2025. No evidence was found of ongoing assessments to affected skin areas, any effective preventative measures and/or interventions to prevent further development of pressure injuries such as turn/reposition every two hours, pressure relieving mattress, protective dressing to area behind ears, daily skin assessments, etc. Review of nurse's note dated 02/18/2025 documented new pressure ulcer noted to the right ear where the cannula sits. Protectors were already in place although they were changed for new ones. [Medical Doctor] and guardian notified. New wound care orders to include right ear entered. On 02/20/2025 at 01:38 PM, V2 (Director of Nursing) said R1 did not admit with any skin issues or irritation to his ears upon admission but developed pressure injuries to both ears from the straps of the oxygen mask. V2 added that R1 was at moderate risk for pressure injury upon admission. On 02/21/2025 at 11:02 AM, V8 (Wound Care Nurse) said upon admission on [DATE], R1 did not admit with any skin issues but he was at risk for developing a pressure injury with a [pressure ulcer risk assessment] score was 14. V8 then said on 02/03/2025, he first identified a stage 3 pressure injury to R1's left ear that measured 3cm x 2cm (length x width), was unable to determine any depth and started a treatment for Medi honey then cover with bordered foam. V8 said he provided wound care Monday through Friday, and the floor nurse would provide wound care on the weekends. V8 added that R1 had weekly skin assessments in place. V8 then said on 02/17/2025, he identified a stage 3 pressure ulcer to R1's right ear that measured 1cm x 1cm x 0.2 cm (length x width x depth) and started treatment for Medi honey sheet. V8 (Wound Care Nurse) added that he didn't see an issue or believed that R1 would develop pressure injuries to his ears from the mask straps so when he recognized an issue to the first ear, he applied protectors to both sides of mask straps as a preventative. V8 also said that at times when he would see R1, the mask would be pulled down and the strap would fold his ear downward then indicated moving forward, interventions should be implemented due to mask movement that could cause friction. On 02/21/2025 at 11:49 AM, V2 (Director of Nursing) said ear protectors were not applied initially to R1 because they did not suspect it was a high area of skin breakdown, but moving forward, any resident who admits in a similar condition and identified as high risk for developing pressure injuries will have ear protectors placed. On 02/21/2025 at 1:19 PM, called the office of R1's physician V11 (Primary Care Physician/Medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145261 If continuation sheet Page 2 of 3 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 145261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Dekalb 1212 South Second Street Dekalb, IL 60115 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)

F 0686 Director) and was informed by receptionist that V11 was out for the week, not reachable and will not return until Monday. Level of Harm - Actual harm Residents Affected - Few On 02/21/2025 at 2:23 PM, when asked if R1's pressure injuries should have been recognized sooner than a stage 3, V2 (Director of Nursing) said staff performed weekly skin assessments and should have looked at R1's face and skin every shift, when providing care or readjusting R1's mask, and when they observed his ear folded down from the mask strap. V2 then said a resident who develops a pressure injury would be considered at higher risk for skin breakdown and if a resident is not able to adjust themselves, they also would be at increased risk for developing a pressure injury. When asked if a pressure ulcer risk assessment should have been completed for R1 after the second injury was identified, V2 (DON) said she would need to follow-up with V8 (Wound Care Nurse) because he may have done one that could be within R1's wound documentation. (No additional pressure ulcer risk assessments were provided.) Pressure Injury and Skin Condition Assessment policy last revised 01/17/2028 reads is part: to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented .a skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary .each resident will be observed for skin breakdown daily during care and on the assigned bath day the CNA (certified nursing assistant) .care givers are responsible for promptly notifying the charge nurse of skin breakdown .at the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145261 If continuation sheet Page 3 of 3