Health inspection·March 14, 2025

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 reoccurance of a pressure ulcer for a resident with a history of wounds and risk factors, as well as initiate a timely and appropriate treatment for 1 of 3 residents (R3) reviewed for pressure ulcers, in the sample of 7. Residents Affected - Few Findings include: On 3/13/2025 at approximately 8:45 AM, V8, Certified Nursing Assistant (CNA) stated R3 has a new open area, about the size of a dime, to her coccyx (buttocks). At this time, R3 also confirmed she had a wound to her bottom. On 3/13/2025 at approximately 10 AM, the facility provided their Resident Matrix. R3 is not listed as having a pressure ulcer. R3's Face Sheet dated 3/13/2025 documents R3 has multiple diagnoses include Diabetes Mellitus, atherosclerosis of bilateral legs, mixed incontinence, muscle weakness, and contractures of the right and left knees. R3's Skin Attention Form dated 3/10/2025 documents a Xon the diagram of a body. This form continues to document, Indicate the area with an 'X' where you notice abnormality or change in color, moisture, temperature, integrity or turgor and answer the questions. If you are not sure if area is a real problem, mark it down anyway. The nurse should assess all areas where the CNA had indicated change. R3's Minimum Data Set (MDS) dated [DATE] documents R3 has a functional limitation in range of motion on both sides of her lower extremities as well as R3 is dependent on staff for rolling from left to right and for transfers from chair/bed to chair. R3's current Care Plan was requested and documents, (R3) is at risk for development and/or decline in current pressure ulcers related to decreased mobility and incontinence. The goal includes, She (R3) will have no new development of pressure ulcers through the next review. It further documents, 3/10/2025re-opened area to coccyx. and 3/13/2025 WCP (Wound Care Plus) to eval and treat as indicated. On 3/13/2025 at 10:15 AM, V2, Director of Nursing (DON) provided a list titled, Pressure Wound Log. This document was dated 3/13/2025 and does not include R3 on it. This Wound Log does not include stage, measurements, or locations of the pressure wounds. At this time, V2 stated currently there is no wound nurse, so he has assumed the responsiblities of wounds in the absense of the wound nurse position. V2 stated he would look and see if R3's pressure ulcer had been assessed/measured. Page 1 of 4 145581 145581 03/14/2025 Autumn Meadows of Cahokia 2 Annable Court Cahokia, IL 62206

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/13/2025 at 10:20 AM, V5, Licensed Practical Nurse (LPN) was observed initiating a treatment to R3's left buttocks. R3 did not have any type of dressing or cream to her buttocks. In the crease of R3's left buttocks was an approximately 1 cm open area. At this time V5 stated she, Just got the order 'fixed' because they just put gauze and tape on it but it needed (the special foam gel dressing). On 3/13/2025 at 11:04 AM, the Pressure Ulcer Log was reviewed with V2. At this time, V2 stated he needed to add R3 to the list. V2 confimed the open area was first identified on 3/10/2025. V2 stated it was an old healed area and had opened back up. V2 confirmed treatment was not intiated until 3/13/2025 and should have been done when it was first reported (3/10/2025). On 3/13/2025 at 11:24 AM, V16, Registered Nurse (RN) stated when an open area is first identified, she would do a whole body skin assessment, measure the wound, call the doctor and get a treatment order in place. V16 stated she would absolutely not just put gauze and tape on the open area. On 3/13/2025 at 11:58 AM, V2 stated he had just obtained measurements on R3's wound to R3's left buttock and it measured 0.5 centimeters (cm) by 1 cm. R3's Physician's Orders dated 3/13/2025 documents, WCP (Wound Care Plus- an outside agency) to eval (evaluate) and treat as indicated. It further documents an order for a gel formula dressing was ordered on 3/13/2025. It continues, Apply to left buttock topically every 72 hours for open area to left buttock. Cleanse area with wound spray, apply wound prep around the outside of the wound and apply (dressing). Change Q (Every) 72 hrs (hours) and prn (as needed). R3's Progress Notes dated 3/10/2025 at 2:03 PM documents, CNA notified me of a new sore area on the lower left thigh (back) on resident. Pink and about 1/2 centimeter in length, pink in color, no bleeding noted. Cleansed with wound cleanser and covered with tape and gauze. Nurse Practitioner notified, will continue to monitor. R3's Progress Notes dated 3/13/2025 at 11:26 AM documents, Np (Nurse Practitioner) gave orders to cleanse area with wound spray, apply skin prep around the outside of wound and (dressing) change Q 72 hrs and prn. The Facility's Skin-Ulcer-Wound Policy dated 10/12/2023 documents, All caregivers are responsible for preventing, caring for, and providing treatment for skin ulcerations. It further documents the purpose of the policy is, To prevent breakdown of tissue or ulcerations and To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations. It continues to document risk factors as impaired/decreased mobility, co-morbidities such as diabetes, exposure of skin to urinary or fecal incontinence and history of a healed ulcer makes pressure ulcers more likely to have recurrent breakdown. This policy documents all orders must be approved by the physician within 24 hours. It also documents, At the time a skin issue is discovered it must be measured. Wounds are 3 dimensional, therefore length, width and depth must be documented if using a measuring instrument. 145581 Page 2 of 4 145581 03/14/2025 Autumn Meadows of Cahokia 2 Annable Court Cahokia, IL 62206

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to perform Range of Motion (ROM) exercises to a resident with contractures for 1 of 3 residents (R3) reviewed for Restorative Programs/Physical Therapy, in the sample of 7. Findings include: R3's Face Sheet dated 3/13/2025 documents R3 has multiple diagnoses include Diabetes Mellitus, atherosclerosis of bilateral legs, mixed incontinence, muscle weakness, and contractures of the right and left knees. R3's Minimum Data Set (MDS) dated [DATE] documents R3 has a functional limitation in range of motion on both sides of her lower extremities as well as R3 is dependent on staff for rolling from left to right and for transfers from chair/bed to chair. R3's current Care Plan was requested and documents, (R3) is at risk for pain (joints), stiffness, edema, redness, decreased ROM, weakness, physical deformity and skin breakdown r/t (related to) diagnosis of arthritis and BLE (bilateral Lower Extremities) contractures. It further documents to provide ROM exercises with daily care as tolerated. It continues to document R3 has self care deficit due to weakness and poor trunk control. It continues to document R3 is at risk for falls, pain and decreased mobility related to bilateral knee contractures and should be receiving a restorative ROM program. R3's Current Physician's Orders were requested and do not include an order ROM to be performed. On 3/13/2025 at approximately 12:10 PM, R3 was observed sitting in a chair, with her bilateral legs bent at both knees. At this time, V8, Certified Nursing Assistant (CNA) stated R3 does have contractures to both her legs and there were no interventions in place for them. V8 stated she does not perform any kind of exercises on R3. At this time, R3 confirmed no one does any exercises on her legs, but she would participate if they did. On 3/13/2025 at 12:13 PM, V2, Director of Nursing (DON) stated the Facility is working on starting a restorative program back up. V2 stated in the meantime, the CNAs assigned to the hall are responsible for completing ROM exercises. V2 stated R3 does have contractures and should be receiving ROM to stretch it out. V2 confirmed R3 was not enrolled in any therapy services at the moment. V2 stated the restorative program is a step below physical therapy. V2 stated the Facility has been without a restorative program for a month or two. V2 stated any resident with contractures should be receiving ROM exercises. On 3/13/2025 at 12:39 PM, V1, Administrator, stated the Facility does not currently have a restorative nurse, but has one starting next week. V1 stated residents with contractures can be referred to therapy services. V1 stated she will get R3 a referral for therapy services. On 3/13/2025 at 12:52 PM, V7, CNA coordinator, stated the Facility did have a restorative program with 4 CNAs that would perform ROM, but they have not had it for months. V7 stated the CNAs assigned to the resident should be performing ROM. 145581 Page 3 of 4 145581 03/14/2025 Autumn Meadows of Cahokia 2 Annable Court Cahokia, IL 62206

F 0688 Level of Harm - Minimal harm or potential for actual harm On 3/13/2025 at 1:17 PM, V1, Administrator, stated she called and got R3 an order for therapy services for positioning and her contractures. On 3/13/2025 at 2:00 PM, V1, Administrator, stated the Facility does not have a policy for contracture prevention/ROM. Residents Affected - Few 145581 Page 4 of 4