Inspection·May 10, 2025

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 implement measures for unstageable wound. This facility also failed to implement wound care treatment orders and develop a wound care plan. This deficiency affects one (R4) of three residents reviewed for Wound/Pressure Ulcer Prevention and management. Residents Affected - Few Findings include: On 5/10/25 at 10:25AM, V5 (Wound Care Nurse) said that R4 sacral wound was identified on 4/28/25. V5 said that R4 had multiple co morbidities and was declining rapidly. On 05/10/25 at 1:20PM V3 (Director of Nursing) said that R4 develop a wound in facility and based on documentation it was observed on 4/26/25 by staff V6 (Certified Nurse Aide) and V7 (Licensed Practical Nurse). V3 said that residents with new skin concerns or wounds should have been notified to Nurse Practitioner or MD for treatment orders, and care plan should be updated with interventions. Treatment orders should reflect on the resident treatment administration record for wound care management. V3 said that there is no treatment administration record for the month of April 2025 for R4, no treatment orders were put in place on the physician orders to reflect wound care. The nurse who identified the sacral wound should have called MD or Nurse Practitioner to obtain treatment orders. On 5/10/25 at 1:35PM, V7 (Licensed Practical Nurse) said that V6 (Certified Nurse Aide) notified her about R4 sacral wound, V7 cleansed area and applied dry border gauze dressing. V7 said she did not notify Nurse Practitioner or MD to obtain any treatment orders. V7 said she knows she is supposed to notify Nurse Practitioner and MD of any new open skin areas, obtain treatment orders and update care plan but did not do it. On 5/10/25 at 1:45PM, V6 (Certified Nurse Aide) said that she noticed the sacral area completely opened and notified V7 (Licensed Practical Nurse). V6 said she documented on R4 shower sheet and gave it to V7. On 5/10/25 at 2:30PM, V5 said that there should have been a wound care order on 4/26/25 when the wound was identified, and care plan should have been updated as well. V5 said she is unsure of what happened. On 5/10/25 at 3:03PM, V1 (Administrator) made aware of above findings, and said that her expectations for wound care management are to have the staff notify the physician or Nurse Practitioner for orders, make sure that there is a treatment administration record in place, and care plans updated. R4 readmitted on [DATE] with diagnosis listed in part but not limited to other encephalopathy, (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: 145758 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 145758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Glenwood 19330 South Cottage Grove Glenwood, IL 60425 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)