Health inspection·January 17, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to assess and treat a wound when it was first identified. This applies to 1 (R1) of 3 residents reviewed for wound care in the sample of 3. Residents Affected - Few The findings include: R1's admission Record (Face Sheet) showed an admission date of 11/22/24. The Face Sheet showed diagnoses to include but not limited to Alzheimer's, Pressure ulcer, contractures of the legs, failure to thrive, and palliative care. R1's admission Minimum Data Set (MDS) from 11/26/24 showed he had short and long-term memory loss. The MDS showed he had limited range of motion in all extremities. The MDS showed R1 was dependent upon staff for every activity of daily living to include oral care, feeding, toileting hygiene, dressing, and personal hygiene. On 1/13/25 at 11:36 AM, V11 (R1's family) addressed an email to the state health department. The email showed, V11 was at the facility on 1/7/25, she was in R1's room during incontinence care, and she noted a wound to R1's scrotum that she was not previously aware of. On 1/16/25 at 10:00 AM, V4 (Wound Care Director) began providing wound care for R1 while (V7 Wound Care Nurse Practitioner) assessed R1's wounds. At the request of the state surveyor, R1's perineal area was assessed, and a quarter sized wound was observed to R1's scrotum. The wound was not draining and was superficial. R1 has black skin tone, and the wound was bright pink. V4 and V7 both stated they were not aware of the wound. V7 provided an order for a petroleum type jelly for protection. V7 stated she would also request an order from hospice for a catheter to promote healing of this wound as well as his other wounds. On 1/16/25 at 11:00 AM, V5 (Certified Nursing Assistant-CNA) stated she reported R1's scrotum wound weeks ago. V5 stated it was also documented in R1's Electronic Health Record (EHR). V5 demonstrated where she would document skin alterations. R1's Shower/Bathing and Skin Monitoring charting from 11/15/24 through 1/16/25 showed no documented skin alterations. On 1/16/25 at 12:06 PM, V5 was informed there were no documented skin alterations to R1's scrotum. V5 was not able to explain this; however, she reiterated R1's scrotum wound had been reported and the wound had been there for several days. (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: 145339 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 145339 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126 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)