Inspection·February 25, 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 follow the physician orders to complete wound care daily as ordered by the physician for one of three residents (R3) reviewed for pressure ulcer. Residents Affected - Few Findings include: R3 face sheet shows R3 is [AGE] year-old male with diagnosis of fracture femur, abnormal gait and mobility, dysphagia, cognitive deficits, lack of coordination, hyperlipidemia, thrombocytopenia, BPH, glaucoma, urinary device, asthma, hypertensive heart and chronic kidney disease with heart failure, hypertension, and stage 3 kidney disease. R3 physician order sheet dated 1/2/2025 shows orders for skin sacrum, cleanse area with wound cleanser, pat dry, apply Medi-honey and calcium alginate and cover with dry dressing one time a day for wound care. R3 treatment administration record dated 2/1/2025 for skin sacrum, there is no initials documented denoting that treatment was rendered. R3's treatment record dated 2/2/2025 for skin sacrum shows there is no initials documented denoting treatment was rendered. On 2/21/25 at 11:29am V7 (Wound care nurse) said she does not have documentation denoting wound care was rendered to R3 on 2/1/25 and 2/2/25. V7 said the treatment administration record is signed after treatment is complete. Facility policy procedure for clean dressing change dated 10/2022 denotes in-part it is the policy of the facility to ensure change dressing in accordance with state and federal regulations, and national guidelines. Verify and review physician orders for procedure. Identify the resident and explain he procedure. Cleanse wound with gauze and prescribed cleaning solution using outward stroke. Apply clean dressing as ordered. Documented the completion of dressing change on the treatment record. R3 physician wound care record denotes on 2/4/2025 unstageable pressure injury to sacrum, measures 11x11x 0.8 cm (centimeters) with undermining of 0.5 cm at 12'oclock. Wound is 30% necrotic tissue, 70% devitalized, non-blanchable tissue. Moderate serous exudate. Odor present. Deteriorated in surface area. Request was made to review supporting documentation denoting R3 received wound care treatment on 2/1/25, and 2/2/2025. The facility failed to present documentation denoting wound care treatment was rendered on 2/1/2025 (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: 145803 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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)