Health inspection·November 19, 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 provide treatments to pressure ulcers as ordered by the physician for 2 (R1, R5) of 3 residents reviewed for pressure ulcer treatments in the sample of 21. Residents Affected - Few The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 was transferred to the local hospital on October 6, 2024 and diagnosed with Covid-19 and altered mental status. R1 returned to the facility on October 11, 2024. On October 21, 2024, R1 was transferred to the local hospital and diagnosed with encephalopathy. R1 was readmitted to the facility on [DATE]. On November 3, 2024, R1 experienced labored breathing at the facility and was transferred to the local hospital where he was diagnosed with acute hypoxic respiratory failure. R1 returned to the facility on November 15, 2024. R1 has multiple diagnoses including, traumatic subdural and subarachnoid hemorrhage, craniotomy, hepatic encephalopathy, gastrostomy tube, cirrhosis of the liver, acute respiratory failure with hypoxia, hypertension, metabolic encephalopathy, pleural effusion, unstageable pressure ulcer, dysphagia, cognitive communication deficit, mitral valve insufficiency, UTI (Urinary Tract Infection), altered mental status, alcohol use, diseases of the pancreas, and history of venous thrombosis. R1's MDS (Minimum Data Set) dated October 31, 2024 shows R1 has moderate cognitive impairment and is totally dependent on facility staff for all ADLs (Activities of Daily Living). R1 has an indwelling urinary and is frequently incontinent of stool. R1 has bilateral upper and lower extremity range of motion limitations. R1's MDS continues to show R1 receives greater than 51 percent of his total number of calories from tube feeding. On September 10, 2024, V5 (WCN/RN-Wound Care Nurse/Registered Nurse) documented R1 was admitted to the facility with an unstageable pressure ulcer. The pressure ulcer measurements were 1.0 cm. (centimeters) by 0.5 cm. by unknown cm. deep. The EMR shows the following order for R1 dated September 11, 2024: Medihoney external gel. Apply to coccyx topically every day shift for skin condition. Clean with NSS (Normal Saline Solution), pat dry. Apply medihoney gel on wound bed. Cover with dry dressing. Change daily. The facility does not have documentation to show the wound treatment was administered as ordered on September 14, 15, 20, 21, 23, 25, 30, 2024 and October 2, 3, 2024. 2. The EMR shows R5 was admitted to the facility on [DATE]. R5 has multiple diagnoses including, heart disease, adult failure to thrive, hypertension, anemia, asthma, chronic kidney disease, dementia, emphysema, feeding difficulties, and abnormal gait and mobility. Page 1 of 2 145710 145710 11/19/2024 Meadowbrook Manor 431 West Remington Boulevard Bolingbrook, IL 60440

F 0686 Level of Harm - Minimal harm or potential for actual harm R5's MDS dated [DATE] shows R5 is cognitively intact and is dependent on facility staff for all ADLs. R5 is always incontinent of urine and frequently incontinent of stool. R5's wound care assessment dated [DATE] shows R5 has a Stage 3 pressure ulcer on her sacrum. The pressure ulcer measurements on November 13, 2024 were 8.0 cm. long by 9.0 cm. wide, by 0.2 cm. deep. Residents Affected - Few The EMR shows the following order for R5 dated November 5, 2024: Medihoney wound and burn dressing external paste. Apply to sacrum topically every day shift for skin condition/wound healing. The facility does not have documentation to show R5's wound treatment was administered as ordered on November 6, 13, 14, and 15, 2024. On November 14, 2024 at 12:37 PM, V4 (WCN/RN) said, I am in charge of the care nurses. There are three of us; me, V5 (WCN/RN), and V9 (WCN/LPN-Licensed Practical Nurse). We do all the treatments in the facility. If the dressing comes off, then the floor nurses will help us out with that, otherwise, we are responsible for doing the dressing changes. On November 18, 2024 at 9:41 AM, V10 (Physician/Medical Director) said he cares for R1 and R5. V10 said he expects nursing staff to follow all orders for wound care treatments. V10 continued to say R1 and R5's wounds did not decline due to missing wound care treatments. On November 19, 2024 at 11:41 AM, V7 (Wound Care NP-Nurse Practitioner) said she is responsible for all wound care orders, and it is her expectation nursing staff provide wound treatments as ordered. The facility's policy entitled Administering Medications, revised April 2019 shows: Medications are administered in a safe and timely manner, and as prescribed. 22. The individual administering the medication initials the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones.24. Topical medications used in treatments are recorded on the resident's treatment record (TAR). 145710 Page 2 of 2