F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Actual harm
Based on observation, interview, and record review the facility failed to perform skin assessments in order
to prevent pressure injuries from developing for 1 of 5 residents (R2) reviewed for pressure in the sample of
6. This failure resulted in R2 developing a facility acquired pressure injury that was not identified until it was
a Stage 3.
Residents Affected - Few
The findings include:
On 9/3/24 at 11:50 AM, R2 was dressed and sitting bedside in his room. R2 had a low air loss mattress on
his bed. R2 said he has a pelvic fracture in two places which causes him some pain. R2 said he is able to
walk with a walker, move in bed, and takes himself to the bathroom. R2 said he got the low air loss mattress
when they found a sore on his bottom. R2 said he didn't have any sores when he came in.
R2's Progress Noted dated 8/6/24 shows R2 was admitted to the facility from the hospital, is alert and
oriented to person, place, time, and situation, and is able to make his needs known. The same note shows
No open areas, skin is intact.
R2's Progress Note dated 8/8/24 shows R2's skin is intact.
R2's Progress Note dated 8/9/24 shows skin intact. There are no progress notes regarding R2's skin until
8/18/24 when R2 was found with a Stage 3 pressure injury to his sacral area.
R2's Wound Management Detail Report dated 8/18/24 shows R2 was found to have an in house acquired
Stage 3 pressure injury sacrum area measuring 1 x 1 cm with serous drainage.
R2's Wound MD Progress Note dated 8/29/24 shows R2 has a Stage 3 pressure injury to coccyx,
measuring 1.5 x 0.3 x 0.1 cm with scant serous exudate.
On 9/4/24 at 10:40 AM, V11 Nurse Practitioner said R2 is alert and uses a walker with minimal assistance.
V11 said she was notified of R2's pressure injury on his sacrum when it was found at a stage 3. V11 said
pressure injuries should be found before they are a Stage 3 and staff should be doing skin assessments
during care.
On 9/4/24 at 11:20 AM, V10 Wound Licensed Nurse Practitioner said R2 was admitted when she was on
vacation. V10 said when she returned from vacation, she did a skin assessment on all of the new residents
and found a Stage 3 pressure injury on R2's bottom. V10 said she notified V11 and got treatment orders
and put pressure reducing interventions in place. V10 said Certified Nursing Assistants (CNA) look at skin
daily during care and then on shower days the CNA is supposed to call the nurse into
(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:
145338
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
145338
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oakwood Rehab and Nursing Center
512 East Ogden 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)
F 0686
Level of Harm - Actual harm
the shower room to do a full skin assessment. V10 said the nurse signs off on the shower sheet that a skin
assessment was done and then if there were new openings the nurse would call the NP and get orders, let
her know of the wound, and notify the Director of Nursing. V10 said R2 is alert and able to turn and
reposition himself but had pain from his fractures and needed reminders to reposition.
Residents Affected - Few
R2's Bath and Skin Report Sheet for August 2024 shows R2 received a shower on 8/8/24, refused on
8/12/24, and received a shower on 8/15/24, and then on 8/18/24. This Report has initials in the Nurse
Signature column for all showers. The shower on 8/15/24 is completed in pencil and has a check mark on
the open area column and an x on the sacral area on the body diagram.
On 9/4/24 at 12:55 PM, V10 reviewed R2's Bath and Skin Report with this surveyor. V10 said R2's shower
on 8/8/24 and 8/15/24 have an x and a check mark in the open area column but the body diagram has no
marking on 8/8/24 only on 8/15/24 where there is an x on the sacral area. V10 said the nurse initialed both
showers but she was unable to decipher who the initials were. V10 said if the CNA found an open area they
are supposed to tell the nurse. V10 reviewed the staff schedule for 8/15/24 and could not determine who
the initials were for the nurse or the CNA and said it could have been agency. V10 said the CNA probably
didn't tell the nurse and the nurse didn't actually do the skin assessment and just signed off on the form.
On 9/4/24 at 1:10 PM, V4 Registered Nurse said she did work on 8/15/24 but that was not her signature on
the shower sheet. V4 said she was not told of R2 having a wound until V10 found it on 8/18/24. V4 said the
nurse is supposed to go into the shower room and look at the resident's skin and then sign the shower
form.
On 9/4/24 at 1:15 PM, R2 said that no one said anything to him about an open area on his bottom during
his showers and the nurses didn't come in during his showers to look at his skin. R2 said the nurse came
into his room, did a skin check and found the sore on his bottom.
The facility's undated Pressure Ulcer and Wound Prevention/Management Program shows Resident's skin
will be inspected during daily bathing, dressing, showering, and incontinency care with special attention to
bony prominences by CNA and staff nurses.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145338
If continuation sheet
Page 2 of 2
