Health inspection·December 30, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately notify a power of attorney about the initiation of treatment for a pressure injury for 1 of 3 residents (R1) reviewed for notifications in the sample of 3. The findings include: R1's Face Sheet printed on 12/30/24 showed R1 admitted to the facility on [DATE]. On 12/30/24 at 11:50 AM, V5 (R1's Power of Attorney) said she was not made aware of R1's pressure injury or that the pressure injury required a dressing until R1 was in the emergancy room on 12/25/24. R1's Progress Note dated 12/19/24 showed the facility was obtaining consent from V5 regarding R1's treatments. R1's Wound Assessment Details Report dated 12/20/24 showed R1 had a pressure injury to her coccyx that measured 0.50 centimeters (cm) x 1 cm x 0.1 cm. The report showed the pressure injury was present on admission. R1's hospital paperwork and hospital medication administration record (prior to being admitted to the facility on [DATE]) did not indicate R1 had a pressure injury or a treatment for a pressure injury. On 12/30/24 at 11:25 AM, V4 (Wound Care Nurse) said he saw R1 on 12/20/24 (the day after R1 admitted to the facility). V4 said R1's pressure injury was considered present on admission. V4 said he contacted the doctor and received treatment orders for the pressure injury. V4 added that R1 did not have any treatment orders for the pressure injury until he obtained them on 12/20/24. V4 said he did not inform V5 of the treatment orders. R1's Order Summary Report printed on 12/30/24 showed an order for R1's coccyx wound. The order was dated 12/20/24. There were no other orders, including discontinued orders, for R1's coccyx wound. R1's Care Management Care Conference document dated 12/23/24 (3 days after R1's coccyx wound treatment order was obtained) showed V5 participated in a care plan. The document showed, Shared clinical updates, wound care management and asked if there were any concerns regarding nursing care and [V5] declined acknowledging understanding of information given. The signature of the person that (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: 145460 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 145460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Lake County 850 E US Highway 45 Mundelein, IL 60060 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)