Health inspection·February 7, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure a resident's prescribed treatment order was changed daily for a resident who has stage 4 left ischial pressure ulcer. This applies to 1 of 3 residents (R5) reviewed for pressure ulcers in the sample of 28. Residents Affected - Few The findings include: 1. R5's Wound Physician Progress note dated 1/10/24 documents stage 4 left ischial pressure ulcer measuring 4 cm (centimeters) x 3 cm x 3.5 cm. Treatment orders include silver alginate daily and cover with foam dressing. R5's Physician Orders Summary (P.O.S.) dated February 2024 shows he has diagnoses including spina bifidia, paraplegia, neuromuscular dysfunction of the bladder and pressure ulcer of sacral region stage 4. The P.O.S. shows orders including wound care left ischial clean with normal saline, pat dry, apply calcium alginate with silver and cover with foam dressing every Monday, Wednesday, Friday (order date 1/10/24). On 2/5/24 at 9:53 AM, V5 (Wound Nurse) was providing wound care to R5. This surveyor asked to observe R5's wound care. V5 said R5 said he does not want to be observed. At 10:25 AM, R5 was observed lying in bed. He said the less eyes on his wound is better. R5 said his wound usually has drainage. On 2/7/24 at 9:23 AM, V5 (Wound Nurse) said R5 has history of chronic wounds. He is being followed by the wound physician at the hospital and she follows the orders. He was on a wound vac prior and his wounds were not improving so the treatment was changed. She confirmed the treatment order was entered three times a week and should have been done daily. R5's Treatment Administration Record for January 2024 and February 2024 shows wound care to Left Ischial clean with normal saline, pat dry apply calcium then cover with foam dressing. Every evening shift Monday, Wednesday and Friday. The T.A.R. shows 15 out of 36 treatments were not provided. Skin Care Treatment Regimen Policy revised 2023 states, It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown .routine daily wound care/treatment/dressing change is administered by the wound care nurse 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 11 Event ID: 145816 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 145816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047 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)