Health inspection·March 7, 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 prevent the development of pressure ulcers and consistent with professional standards of practice for two of three (R1, R2) residents reviewed for pressure ulcers, in a sample of four. Residents Affected - Few Findings include: 1. R1's Facesheet documents an admission date of 11/2/2023. Diagnosis include Chronic Obstructive Pulmonary Disease, Pancytopenia, Multiple Myeloma, Cardiomegaly. R1's Minimum Data Set (MDS), dated [DATE] documents R1 has no pressure ulcers and is at risk for the development of pressure ulcers. R1's MDS, dated [DATE] documents R1 is cognitively impaired. R1's MDS dated [DATE] documents R1 requires set up and clean up with eating. Is dependent on staff for showering. R1's care plan dated 2/22/2024 documents Actual Pressure Ulcer; Site(s): Left heel, Stage 3. Right heel, Stage 4. Requires assist with turning and repositioning: Poor Nutritional status, requires assist with turning and repositioning, Incontinence. Healing may be unattainable due to ongoing medical decline and decrease in appetite. R1's Braden Scale assessment dated [DATE] documents R1 is at risk for the development of pressure ulcers. R1's Bruise/Skin Assessment, dated 2/26/2024, documents, Nursing description, purplish discoloration noted to left dorsal foot. (R1) unable to give description. Immediate action taken, Upon assessing (R1) wears foam heel protectors with velcro straps that are placed over dorsal area of both feet. Discoloration aligns with strap. (R1) voices no pain, discomfort. Heel protectors removed. Dc'd with heels to be floated. (R1) receives Xarelto, Aspirin, and Hydrocodone with all increased risk for bruising. Notes left dorsal foot noted to have purplish discoloration. (R1) wears heel protectors with Velcro which is applied to top of foot. Root Cause: (R1) receives anticoagulant daily which increases risk of bruising. Heel protectors DC'd with heels to be floated. R1's progress notes, dated 2/26/2024 at 6:41PM, documented, (R1) Has new bruising and open abrasion to R (Right) dorsal foot and bruising to L (left) dorsal foot. R 5th digit toenail appears to be pulling off. Resident does not report any pain and does not recall any event that would cause injury. Area's measured and cleaned; dressing applied. Notifications completed. Page 1 of 3 145286 145286 03/07/2024 Staunton Health and Rehab Ctr 215 West Pennsylvania Avenue Staunton, IL 62088

F 0686 Level of Harm - Minimal harm or potential for actual harm R1's skin and wound assessment dated [DATE] documents, Stage 3 pressure wound to left heel, in house acquired .5cm (centimeters) X .7cm x .9cm slow to heal, improving. R1's skin and wound assessment dated [DATE] documents, Right heel stage 4 full thickness in house acquired 4.6cm x 2.0cm x unable to determine. Residents Affected - Few On 3/5/2024 V8, Wound Company Physician's Assistant, measured wounds to R1's dorsal left and right feet. Left dorsal foot wound measured 0.1cm x 0.1cm x 0.1cm. Right dorsal superior foot wound measured 0.3cm x 0.3cm. Right dorsal inferior foot wound measured 0.9cm x 2,4cm x 0.1cm. On 3/5/2024 at 11:00AM V1, Administrator, stated (R1) was wearing the float boots and the straps caused the bruising on top of her heals. She takes an anticoagulant, aspirin, and an anti-inflammatory also. We now stopped using the boots and are just floating her heals. On 3/5/2024 at 11:15AM V3, MDS Coordinator, Licensed Practical Nurse, LPN, stated, (R1) received the bruising from the float heals she was wearing. So now they aren't to be used and are to just float her heels. We found wounds on her feet fresh and knew what caused them. On 3/5/2024 at 2:45PM V12, Certified Nurse Assistant (CNA), stated, I took care of (R1) and saw the bruises to the tops of her feet. It was from the floating boots she was wearing. They must have been on too tight. Now we aren't using the float boots. We are using a pillow and floating her heels that way. The residents get repositioned and incontinent care every 2 hours. 2. R2's Face sheet documents an admission date of 10/22/2023. Diagnosis includes Chronic Obstructive Pulmonary Disease, Pulmonary Fibrosis, Dementia, Chronic Kidney Disease. R2's MDS dated [DATE] documents R2 is cognitively impaired. R2 requires partial to moderate assist with eating. R2 is dependent for toileting, requires substantial assistance with showering, is dependent for dressing and walking 10 feet not attempted. R2's MDS dated [DATE] documents R2 had no pressure ulcers or skin tears. R2's Braden scale for pressure sore development documents R2 is at risk for pressure sore development. R2's Progress Notes dated 1/28/2024 documents Hospice nurse here new order, clean area on buttocks with wound cleanser and apply medicated ointment to wound bed and cover with calcium alginate and apply (foam wound dressing) daily. R2's Skin/wound assessment dated [DATE] documents Penis in house acquired, new 0.5cm x 0.9cm x 0.8cm scab. Coccyx in house acquired, new.2cm x .6cm x .5cm Left elbow lateral in house acquired 4.4cm x 5.1cm x 2.2cm. V5, Registered Nurse, RN and V3, Licensed Practical Nurse, LPN, provided wound care to R2. Treatment to coccyx as ordered. R2's peri area very reddened and excoriated. On 3/1/2024 at 1:00PM V11, CNA, stated, We change and reposition residents every 2 hours, especially those with sores. 145286 Page 2 of 3 145286 03/07/2024 Staunton Health and Rehab Ctr 215 West Pennsylvania Avenue Staunton, IL 62088

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/5/2024 at 10:00AM, V7, Wound nurse, stated We aren't going in R2's room for wound care. He is actively dying, and a lot of family are there. Facility policy with a revision date of 8/31/2023 states To provide guidelines that will assist nursing staff in prevention, identification, and appropriate treatment of pressure ulcers. Prevention program including turning and positioning will be utilized for all residents who have been identified of being at risk for developing pressure ulcers. The facility will initiate an aggressive treatment program for those residents who have pressure ulcers. 145286 Page 3 of 3