Inspection·January 3, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and identify a resident's pressure injury to her right lower leg until it was a stage 3 acquired pressure injury from a medical device. This applies to 1 of 3 residents (R2) reviewed for acquired pressure injuries in the sample of 3. Residents Affected - Few This resulted in R2 sustaining a facility acquired stage 3 pressure injury. The findings include: R2's face sheet shows R2 is [AGE] year old who was originally admitted to the facility on [DATE], with diagnoses that include right femur fracture that had undergone hip surgery, history of falling, and diabetes. , R2's Braden scale (predicting pressure score risk), dated 10/30/23, shows R2 is at risk for developing pressure. R2's skin admission assessment, dated 10/11/23, shows R2 had no pressure injury except a surgical incision to right hip. R2's hospital Discharge summary, dated [DATE], shows an order for R2's right lower extremity to be non weight bearing, and the knee immobilizer to be on at all times. R2's care plan, dated 10/12/23, shows R2 was at risk to develop further skin breakdown, but did not include R2's use of the immobilizer or any care that needs to be done when wearing a knee immobilizer. R2's Wound Evaluation Management Summary, dated 11/1/23, was when R2's pressure injury was discovered to her right lower lateral calf that was a stage 3 measuring 6.5 centimeters (cm) x 2.5 cm x 0.1 cm. The Facility Wound Report, dated 1/3/23, provided to this surveyor shows R2's facility acquired pressure injury to her right lower lateral calf was now a stage 4 measuring 3.5 cm x 1.0 cm x 0.1 cm . On 1/3/24 at 10AM, R2 was in bed on a low air loss mattress. R2's right leg was suspended with a pillow. R2 said she fell at home, hurt her right leg, and had surgery. R2 said she now has a wound at the back of her right leg, but cannot recall what happened. V4 (Wound Nurse), who was also in R2's (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: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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)