Health inspection·March 15, 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 interview and record review the facility failed to identify a pressure injury before becoming unstageable and failed to provide treatment to moisture associated dermatitis. These failures resulted in R4 developing an unstageable pressure injury to the sacrum. This applies to 1 of 4 residents (R4) reviewed for pressure injuries in the sample of 11. Residents Affected - Few The findings include: On 3/15/24 at 11:34 AM, V10 Wound Licensed Practical Nurse (LPN) said R4 has pressure injury on her sacrum that was acquired at the facility and has been treated for a while. V10 said she is new to the facility and was not here when R4's wound was found. V10 said nursing staff does daily skin checks on residents during care and showers. V10 said she does weekly skin assessments for residents with wounds. V10 said any skin issue noted should be reported to the nurse and an assessment of the wound including measurements should be done and documented. V10 said interventions including treatments will then be implemented. R4's admission Skin assessment dated [DATE] shows R4 was admitted on [DATE] with blanchable redness to her sacrum and shows R4 is at very high risk for skin impairment. R4's admission Skin assessment dated [DATE] was done by V13 Previous Wound LPN and shows skin intact. R4's Care Plan dated 12/11/23 shows resident has activity of daily living self-care performance deficit related to general weakness post hospitalization, cerebral infarction due to thrombosis of middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting Right dominant side, altered mental status; requires assist of 2 staff members for bed mobility and transfers; incontinent of bowel and bladder; and is at risk for skin impairment. R4's Progress Note dated 12/11/23 by V13 shows skin intact. R4's Physician Note dated 12/13/23 shows Skin Common normals: no wounds. R4's Shower Sheet dated 12/17/23 shows R4's left buttocks is circled and labeled discolored. R4's Shower Sheet dated 12/20/23 shows R4's lower right and left buttock is circled and labeled 7 (indicating scratch per the assessment key). R4's Progress Notes from 12/14/23 to 12/27/23 does not contain progress notes or weekly 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 2 Event ID: 145623 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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)