Inspection·April 3, 2024

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 interview and record review, the facility failed to follow its policy of implementing care plan interventions to prevent the further decline of pressure ulcers, for one of three residents R100 reviewed for pressure ulcers, in a sample of 31. Residents Affected - Few FINDINGS INCLUDE: The facility policy, Skin Prevention, Assessment and Treatment, dated (revised) May 2, 2022 directs staff, Purpose: To identify factors that place the residents at risk for the development of pressure ulcers; To implement appropriate interventions to prevent the development of clinically avoidable wounds; To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown; To promote healing of existing pressure ulcers. Residents identified as high risk should be addressed in the resident's care plan to assure appropriate interventions to manage the risk are implemented. Care Plan interventions include: Wound Consultant review; Registered Dietician review; Nutritional supplement; Encourage or turn and reposition on a resident centered time frame (approximately every 2 hours); Use pillows, pads, etc. to aide in positioning, cushion bony prominence's and elevate heels off surface; Encourage activities such as range of motion, ambulation and exercises as tolerated; Practice good transfer techniques to avoid friction and shearing; Keep linens clean and wrinkle free; Keep skin clean and dry; Incontinent care after each incontinent episode; Provide pressure relieving device or cushion on surfaces as indicated; Inspect skin daily for reddened areas or breakdown; Monitor cast, braces, splints and compression bandages for skin irritation; Encourage to maintain adequate nutrition and hydration; Showers at least two times weekly; Nails maintained to promote cleanliness, prevent infection and enhance sense of wellbeing; Arm sleeves, leg protectors; Pad frequently bumped areas. Wounds are treated and based on the etiology of the wound. R100's March 2024 Physician Order Sheet documents that R100 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease, Urinary Tract Infection, Malignant Neoplasm of the Rectum and Diarrhea. R100's Nursing admission Assessment, dated 3/23/24 and signed by V5/Licensed Practical Nurse includes the following Skin Issues, Left ear, Pressure, 1.3 CM (Centimeters) X 0.3 CM, Stage 1; Right Buttock, Pressure, 5.0 CM X 2.0 CM, Stage 1 and Right Buttock, Pressure, 5.0 CM X 2.0 CM, Stage 1. No admission Care Plan to address R100's admission skin conditions and interventions to prevent further deterioration of R100's skin, is present in R100's medical record. R100's Care Plan, dated 3/25/24 includes no focus area to address R100's newly acquired pressure ulcer, or interventions to prevent further deterioration of R100's skin. (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 6 Event ID: 145604 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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)