Inspection·February 22, 2026

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 identify a pressure wound prior to becoming a stage 3 for a resident at risk for pressure ulcers (R1) and failed to ensure pressure relieving interventions were implemented for 2 of 3 residents (R1, R4) reviewed for pressure ulcers in the sample of 7.The findings include:1. R1's face sheet showed she was admitted to the facility 1/30/23 with diagnoses to include hemiplegia and hemiparesis, arthritis, secondary gout, hyperlipidemia, hypothyroidism, stage 3 chronic kidney disease, depressive episodes, Parkinson's disease, and pressure ulcer of left buttock. R1's facility assessment dated [DATE] showed she had severe cognitive deficits, was dependent on staff for most cares, and was at risk for developing pressure ulcers. Residents Affected - Few R1's 1/15/26 Weekly Wound Evaluation showed, . Sacrum. Pressure Injury (In-House Acquired) . Stage 3. Length: 5 cm. Width: 1.5 cm. Depth: UTD (unable to determine) . R1's care plan initiated 7/31/24 showed, [R1] has the potential and actual impairment to skin integrity of the sacrum related to fragile skin, incontinence; Pressure area to sacrum (1/15/26) . R1's care plan initiated 2/15/23 showed, [R1] is at risk for skin breakdown related to hemiplegia/hemiparesis, impaired mobility. Assess for and provide appropriate pressure relieving devices. Assess for changes in skin condition each shift. On 2/22/26 at 9:35 AM, R1 was lying in her bed. R1's tan inflatable heel protector boots were observed to be under the edge of the dresser nearby R1's bed. R1's heels were lying directly on R1's air mattress. On 2/22/26 at 12:54 PM, R1 was receiving wound care by V6 (Wound Care Nurse). V8 CNA (Certified Nursing Assistant) was assisting V6 to position R1. R1 was lying in bed during care, she was observed to be wearing blue heel protector boots on both feet. V6 said R1 does not have any wounds on her heels. V6 said there is no order for R1 to wear heel protector boots, but she feels R1 should wear heel protector boots due to her condition and that is the reason the boots are in place. The tan heel protector boots were no longer under the dresser. V6 said she brought R1 new heel protector boots because her old ones were dirty. On 2/22/26 at 1:24 PM, V12 LPN (Licensed Practical Nurse/Treatment Nurse) said R1's sacral wound was identified when a CNA was getting R1 up for the day and told me she had a wound on her bottom. V12 said it is her understanding that the nurses should be documenting a weekly skin check. The reason to do weekly assessments is to make sure people aren't developing wounds and do to add more preventative measures. We would want to know about the wound right away so if the staff see breakdown happening, we will want to address it rapidly. V12 said she doesn't believe R1 wears heel protectors. (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: 145269 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 145269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hope Creek Nursing & Rehab 4343 Kennedy Drive East Moline, IL 61244 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)