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. (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 3 Event ID: 145286 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 145286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Staunton Health and Rehab Ctr 215 West Pennsylvania Avenue Staunton, IL 62088 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)