Inspection·November 7, 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 implement interventions to prevent pressure ulcers and failed to identify a pressure ulcer for 2 of 3 residents, R1 and R3, reviewed for pressure injuries in the sample of 3. These failures resulted in R1 developing a Stage 3 sacral pressure wound which later became an infected Stage 4 pressure ulcer and R3's pressure wound not receiving wound care treatment until it was an unstageable pressure injury. Residents Affected - Few The findings include: On 11/6/24 at 10:42 AM, V4, Wound Care Nurse, V7, Registered Nurse, and V8, Certified Nursing Assistant transferred R1 from her chair to her bed to provide wound care. R1 had a half dollar coin sized wound to her sacrum. R1's admission Record dated 11/7/24 shows R1 was admitted to the facility on [DATE]. R1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation shows R1 was At Risk on 10/20/23, was a High Risk on 11/3/23, a Moderate Risk on 12/13/23 and 1/4/24, High Risk again on 1/15/24 and Moderate Risk on 4/18/24. R1's Care Plan initiated on 10/20/23 shows R1 has an ADL (activities of daily living) self-care performance and functional mobility deficit related to confusion, dementia, and impaired balance. On 11/1/23, R1's care plan identifies she is incontinent of bowel and bladder. R1's care plan does not identify that she is at risk to develop pressure injuries with corresponding prevention interventions. R1 is totally dependent on staff for toilet use. R1's Full Body Skin Assessment effective 10/20/23 shows R1 has no wounds. R1's Wound Evaluation dated 5/8/24 shows R1 has a new, facility acquired, Stage 2 pressure wound of her butt crack. R1's Wound Evaluated dated 5/9/24 which was completed by V4, shows R1 has a Stage 3 facility acquired pressure wound of her sacrum. R1's Wound Evaluation & Management Summary completed by the Wound Care Physician, V5, on 5/9/24, shows the visit is an initial evaluation of R1's sacral wound and confirms R1's sacral wound is a Stage 3 Pressure Wound. R1's Wound Evaluation & Management Summary dated 7/18/24 shows R1's Stage 3 sacral Pressure Wound merged with a non-pressure wound of her right upper medial buttock and became a Stage 4 sacral pressure wound with odor, heavy serosanguinous exudate, and 100 percent necrotic tissue. R1's sacral wound culture collected 7/25/24 shows the wound has become infected by Escherichia coli (E-coli), and Morganella morganii. R1's Order Recap Report dated 11/7/24 shows R1 was prescribed an antibiotic on 7/30/24 for eight days related to her wound culture. R3's admission Record dated 11/7/24 shows he was admitted to the facility on [DATE]. R3's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 4/11/24 shows he was a Very High Risk. R3's Skin/Wound Note dated 4/12/24 at 3:17 PM shows R3's sacrum is clear. R3's Skin/Wound Note dated 5/23/24 at 5:31 PM shows R3 has MASD (moisture associated skin damage) to sacrum/coccyx, dry healing, also present upon admission, but much improved, this is not a pressure injury. R3's Skin/Wound Note (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: 145739 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 145739 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home for the Aged 800 West Oakton Street Arlington Hts, IL 60004 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)