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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure the prescribed treatment orders were implemented
and changed daily for a resident with wound ulcers. This applies to 1 of 3 (R1) residents reviewed for quality
of care in the sample of 3.
Residents Affected - Few
The findings include:
R1's face sheet shows he is [AGE] year-old male admitted to the facility on [DATE]. R1's diagnoses include
cerebral infarction, anemia, rheumatoid arthritis with rheumatoid factor of left hand, unspecified dementia,
unspecified osteoarthritis, and bipolar.
R1's Wound Physician Progress note dated 1/17/24 documents non-pressure chronic ulcer to left lower leg
with fat exposed measuring 15 cm (centimeter) x 10 cm x 01.cm. A new ulcer identified to the right thigh
measuring 13 cm x 5 cm x 0.1 cm. The treatment orders for the left lower leg/knee and right thigh include to
cleanse with normal saline apply topical gentamycin ointment, cover with adpatic, abdominal pad (abd),
and kerlix.
R1's Treatment Administration Record for January shows orders dated 1/17/24 to cleanse the left knee and
right thigh with normal saline then apply gentamycin to the wound bed. On 1/26/24 the T.A.R shows orders
(prescribed on 1/17/24, nine days later) for left knee and right thigh cleanse daily with normal saline, apply
topical gentamycin ointment, cover with adpatic, then secure with abd/kerlix. The T.A.R shows the incorrect
treatment was applied for nine days. The T.A.R shows 2 out of 6 missed treatments were not documented
from 1/26/24 to 1/31/24 for the left knee and right thigh.
R1's Wound Physician Progress note dated 2/14/23 documents non-pressure chronic ulcer to left lower leg
with fat layer exposed (left knee to shin) measuring 15 cm (centimeters) x 10 cm x 0.1 cm. The second
non-pressure chronic ulcer to the right thigh measuring 9.8 cm x 5 cm x 0.1 cm. The treatment orders for
the left knee and right thigh include to cleanse daily with saline, apply topical gentamycin and
triamcinolone, cover with adaptic and abd pad and kerlix.
R1's Treatment Administration Record (TAR) for February 2024 shows orders to cleanse the left knee and
right thigh with normal saline, apply gentamycin, cover with adaptic and abd pad and kerlix. The T.A.R
shows orders on 2/14/24, apply to left knee/shin daily, cleanse with normal saline then apply gentamycin
then triamcinolone to wound bed, cover with adpatic then secure with abd/gauze. The T.A.R did not show
the new treatment orders for the right thigh for 2/14/24. The T.A.R shows the treatments were not
documented for the left knee and right thigh 3 out of 15 days.
On 3/11/24 at 12:50 PM, V5 (LPN) said R1 was being followed by the wound physician weekly. V4
(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:
145453
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
145453
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden Terrace of McHenry Rehab
803 Royal Drive
McHenry, IL 60050
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
(Former Wound Nurse) would round with the physician, and he would in put any new treatment orders. V5
said he followed the treatment order that was in the electronic medical record. If the treatment was changed
it should be documented. Not providing the prescribed treatment could pro-long the wound from healing
and have a risk for infection.
On 3/11/24 at 1:01 PM, V2 (Interim DON) said V4 (Former Wound Nurse) left the facility mid-February. The
wound nurse would update the orders in the residents' electronic medical records. The prescribed orders
should be followed.
The facility's Prevention and Treatment of Pressure Injury and other Skin Alterations Policy dated 3/21,
states, Implement preventative measures and appropriate treatment modalities for pressure injuries/or skin
alterations .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145453
If continuation sheet
Page 2 of 2
