Inspection·April 11, 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 review of records, interviews and observations facility failed to follow preventive measures to address sacral pressure ulcer care for 1(R2) out of 3 residents for a total of 3 residents reviewed for skin care. This failure resulted to one resident (R2) sustaining pressure ulcer deterioration. Residents Affected - Few Findings include: R2 is [AGE] years old, initially admitted on [DATE]. R2's medical diagnosis includes Parkinson's disease and muscle weakness. R2 was seen on 04/08/2025 at 12:30 PM, in his room alert and verbally able to response within topic during conversation. R2 replied when asked if he has wounds, Yes, I have on my back. R2 stated that dressing was not change yesterday and today. But was changed a couple of weeks ago. R2 was seen laying on his back. When asked if staff are turning him (R2) on his side? R2 replied, No, they don't turn me on my side. They turn me when they change my dressing on my back. But not daily. R2's feet seen pushing on the footrest without heel protector. Per V6 (Nurse Practitioner Wound) clinical notes dated 03/12/2025, 03/21/2025 and 03/26/2025 R2's sacral pressure ulcer was deteriorating. V6 ordered to place R2 on side lying position every two (2) hours. And to turn and reposition every two (2) hours. R2's Treatment Administration Record (TAR) for March and April 2025 documents that multiple days for full eight (8) hours shift of turning and repositioning every two (2) hours were not signed as being performed. Both facility skin assessments and V6's sacral pressure ulcer assessment documents substantial increase in size. V6 assessment documents, from 0.25 square centimeters on 02/26/2025 to 0.50 square centimeters on 03/12/2025 an increase of 100%. Then further increase in size to 0.80 on 03/26/2025. R2's pressure ulcer was staged as 2 on 12/05/2025 by V16 (Nurse Practitioner Wound) later became stage 3 that indicates wound deterioration. Discrepancy of R2's March and April treatment administration records (TARs) were identified. TAR provided by facility on 04/08/2025 does not document signing of turning and repositioning as ordered by physician for the whole eight-hour shift on multiple days. TAR provided by facility on 04/09/2025 was modified by signing all days that were not signed including physician order for turning and repositioning. R2's wound plan of care document turning and repositioning as part of intervention for pressure ulcer prevention and improvement. On 04/09/2025 at 10:55 AM, V7 (Assistant Director of Nursing / Wound Coordinator) stated that included on R2's intervention to treat sacral pressure ulcer is to turn and reposition. And that a pillow is placed on his side to relieve pressure. V7 when asked about purpose of turning and repositioning said, It lift off prolonged pressure. V7 stated that resident who stays for a long time in the same position will get redness or stage one (1) pressure ulcer. V7 said, It is very important to reposition. (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 5 Event ID: 145796 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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)