Health inspection·July 3, 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 interviews and record review, the facility failed to properly assess one resident (R1) for skin breakdown; and failed to prevent, recognize and treat a new wound that was acquired in the facility for 1 resident (R1) out of 7 residents reviewed for nursing care. This failure resulted in R1 being sent out to the hospital on 5/29/24 for altered mental status in which it was discovered R1 had a unstageable wound to the sacrum and again R1 was evaluated in the hospital on 6/5/24 where R1's sacral wound extended to the anus and required surgical debridement. Residents Affected - Few Findings include: R1 is an [AGE] year old with diagnosis including but not limited to: Muscle weakness, abnormalities of gait and balance, cognitive communication deficit, cerebral infarction, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. On 7/01/2024 at 10:10 AM, V1 (Administrator) said, R1 has been discharged from the facility. He went to the hospital on 6/5/2024 and the family decided to take him home from the Hospital. (R1 was sent on 6/5/24 to the hospital for wound evaluation) On 7/1/2024 at 10:15 AM, V6 (R1's family) said, There have been times that I have gone to visit my dad (R1) and noticed that he smelled of urine and feces. He (R1) had a rash and wound on his scrotum. He (R1) had developed a wound on his back that spread to his anus. It was so deep that he had to have surgery and also had a colostomy bag placed. He (R1) had necrotic tissue that had to be removed and he also had formed infections in the wound. He (R1) is still not completely healed from the wound. My dad (R1) did not have any wounds when he was admitted to the facility on [DATE] and now he (R1) has an unstageable wound from which he (R1) is having many complications. The facility didn't prevent my dad's pressure wound from forming and did not treat my dad (R1's) wound until it was too late. He (R1) developed the pressure ulcer in the facility, before he was even hospitalized . He (R1) then got a wound infection in the facility and went back out to the Hospital for the infection. On 07/02/2024 at 1:12 PM, V14 (ADON/ Assistant Director of Nursing) said, I help with wounds sometimes when the wound nurse is not here. On 07/02/2024 at 1:12 PM, V14 said, R1 was incontinent. He (R1) was not alert and oriented and will not call for help if he is wet. For incontinent patients, they are usually rounded on every two hours to reposition and change. I was not in the facility on the day that R1 was readmitted to the facility. I live close by, so I have no problems coming into the facility to assess a wound. I was not aware of R1's wound. I (V14) am not sure why the wound care orders were not entered until 6/2/2024 because he (R1) came back to the facility on 5/31/2024. I was not aware of R1 having any 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 3 Event ID: 145767 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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)