Health inspection·September 29, 2022

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide care consistent with professional standards to prevent pressure ulcer development for 1 of 1 residents (R135) reviewed for pressure ulcers in the sample of 21. Residents Affected - Few Findings included: On 9/26/2022 at 9:30am, V8 (Family) stated R135 was admitted to this facility on Tuesday 8/23/2022 for therapy after having left hip repair surgery resulting from falling and fracturing his hip. V8 stated R135 was discharged on 8/31/2022. V8 stated on 8/31/2022 after lunch, R135 had been discharged from this facility and admitted to a different facility and was waiting for the new facility to pick him up when he became very ill. V8 stated the family decided to have R135 sent to the local emergency room instead of going to the new facility. V8 stated R135 was admitted to the hospital due to septic shock caused by an infected bedsore that R135 had newly developed after being admitted to the nursing home on 8/23/2022. On 9/27/2022 at 1:00pm, V2 (Assistant Director of Nursing/ADON) stated R135 did not have a pressure wound to his bottom when he was admitted to this facility. After reviewing R135's medical records, V2 stated the nursing staff first documented R135 having an open area to his coccyx on 8/31/2022 just prior to him being discharged from this facility. V2 stated the reason R135 did not have any orders to treat the open area to his coccyx because there was not time to contact R135's doctor before R135 left the facility. V2 stated R135 was assessed as high risk for pressure ulcers when he was admitted to this facility on 8/23/2022. V2 stated interventions in place to prevent R135 from developing skin break down were pressure relieving mattress and a special cushion for R135's chair that's relieves pressure. A Nurses Note in R135's medical record dated 8/23/2022 at 3:00pm documented R135's admission skin assessment as both heels firm, 0 (zero) open areas to skin, 0 (zero) redness . On 9/26/2022 at 1:00pm, V12 (Physical Therapy Director) stated she worked with R135 everyday while he was admitted to this facility. V12 stated R135 was very weak and frail when he was admitted . V12 stated on 8/27/2022 about 10:30am, V12 was working with R135, and the nursing staff was assisting her. V12 stated at this time the nursing staff had first noticed R135 had an open area to his bottom. V12 said she made note of it in her treatment note that day. V12 stated she recommended R135 use a special chair cushion to relieve pressure on his bottom. V12, stated she obtained the cushion and she and the nursing staff placed it under R135 after getting R135 up in his chair that day. V12 stated R135 said the cushion helped a lot and he felt better sitting on the new cushion. A Physical Therapy Treatment note dated 8/27/2022 at 11:02am, documented the following: Worked on (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: 145628 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 145628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Nursing & Rehab Center 1115 North Wenthe Effingham, IL 62401 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)