Health inspection·February 26, 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 their pressure injury prevention and wound care management policy for one resident who was at moderate risk for skin breakdown by not implementing an air loss mattress, delay in evaluation by wound care doctor, failing to document skin assessments on admission/weekly, failure to obtain physician orders and document treatments. This affected one of three residents (R1) reviewed for wound care. Residents Affected - Few Findings include: R1 was readmitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, anemia, gastrointestinal hemorrhage, hypertension, and heart disease. R13's Braden scale dated 2/13/25 documents moderate risk for skin breakdown. R1's admission screener dated 1/30/25 document under skin coccyx tiny skin opening. R1's progress note dated 1/31/25 documents: Readmit from skilled unit. Seen by V5 (MD),orders verified and noted. Skin check done. With skin discoloration [greenish ] in back of right hand, with brownish skin discoloration in left upper thigh. Scattered aged brownish spots on back. With redness in both heels, applied heel protectors. R1's progress note dated 2/7/25 documents: Noted two open skin in sacral area, measures #1 1.5 centimeters (cm) x 1 cm #2 1cm x1 cm. Also open skin on right hip 1 cm x 1 cm applied dry dressing and barrier cream to surrounding area. MD notified, refer to Home Health for wound care. R1's physician orders dated 2/7/25 created date 2/9/25 documents: Right buttock open skin cleanse with wound cleanser, pat dry, apply bacitracin then foam dressing twice a day until seen by home health. On 2/13/25 order hold transfer to skilled. R1's physician orders dated 2/7/25 created date 2/9/25 documents: Open skin sacrum cleanse with wound cleanser ,pat dry, apply bacitracin and cover with foam dressing twice a day until seen by home health. On 2/13/25 order hold transfer to skilled. There was no documentation of any home health visits from 2/7/25-2/13/25. R1's progress note dated 2/13/25 documents: Resident moved to skilled unit for rehab/ post hospitalization. Medications endorsed to nurse; verbal report given. R1's skilled progress notes do not document any admission note or completed skin assessment on Page 1 of 3 145852 145852 02/26/2025 Eden Vista Prospect Heights 700 East Euclid Avenue Prospect Heights, IL 60070

F 0686 2/13/25. R1's medical record did not document any skin or wound assessment until 2/18/25. Level of Harm - Minimal harm or potential for actual harm R1's wound evaluation dated 2/18/25 documents: pressure stage 3 to coccyx measuring length 2.57 centimeters (CM) x 0.96 cm width x 0.3 CM depth. Present on admission. R1's wound evaluation dated 2/19/25 documents MASD_ incontinence associated dermatitis to left gluteus measuring 3.66 CM length x 2.52CM width x 0.2 cm depth. Inhouse acquired. Residents Affected - Few R1's physician orders do not document any wound or treatment orders when transferred to skilled unit on 2/13/25. R1's medication and treatment record do not document any treatments to R1 on 2/13/25 until 2/18/25. R1's physician order dated 2/18/25 with start date of 2/19/25. Coccyx cleanse with normal saline. Pat dry. Apply Medi honey and cover with bordered dressing every day. Discontinued 2/19/25. R1's physician order dated 2/14/25: Wound consult On 2/25/25 at 3:38PM, V2(DON) said skin assessment are done weekly by staff. On memory care if there was a wound reported it would be referred to home health for treatment. V2 said a referral was sent to home health but unsure what happened. V2 was requested to provide documentation of referral but none provided during the survey. V2 said home health did not evaluate R1's wounds and he was moved to skilled unit for treatment and therapy. V2 said staff should conduct a skin assessment when moving to another unit and was unable to find or locate any documentation of R1's skin assessment on 2/13/25. V2 said residents should have a treatment in place and documented in the medical record. V2 was unable to find, present or locate any documentation of treatment orders or administration of treatment for R1 from 2/13/25 through 2/18/25. V2 said R1 was expected to have an air loss mattress when he moved to skilled because of the wounds. V2 was unable to recall if he was provided an air loss mattress. On 2/26/25 at 9:35AM, V2(DON) said R1 was not seen by wound doctor on 2/14/25. V2 said regular wound doctor was not here and a replacement doctor was sent but did not see all the residents, including R1. On 2/26/25 253pm V6 (wound care MD) said he saw R1 on 2/19/25 for initial visit. V6 said he was unsure why R1 was not seen on 2/14/24. R1 was on group one mattress which is a pressure relieving mattress not an air loss mattress. V6 said he put in orders for air loss mattress after visiting due to wound being a stage three pressure sore. V6 said he would have expected some treatment to be in place for wounds to prevent infection prior to visit. V6 said staff can call him with any concerns or new wounds and does not recall any calls or concerns related to R1. On 2/26/25 at 1:03PM, V5(MD) said she would expect an order for any treatment for a open wound and all orders to be followed as ordered. Initial wound evaluation by V6(wound MD) dated 2/19/25 documents support surface group 1. Under wounds stage three pressure sore measuring 2.5 centimeters (CM) length x 3.5 CM width x 0.1cm depth. Under recommendations air loss mattress. Wound two moisture associated skin damage measuring 5.5 CM length x 4.5 CM width x o.1cm depth R1's mattress delivery order submitted 2/19/25 and delivered stat on 2/19/25. R1's physician order dated 2/18/25: may use air loss mattress. Please verify it's in good working condition. 145852 Page 2 of 3 145852 02/26/2025 Eden Vista Prospect Heights 700 East Euclid Avenue Prospect Heights, IL 60070

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Facility pressure injury prevention and wound care management policy revised 3/4/24 documents: the purpose of the policy is to provide healthcare staff with the standards of care and the processes to be followed by all residents. To identify factors that places the resident at risk for development of pressure injuries and to implement appropriate interventions to prevent the development of clinically avoidable wounds, to promote systematic approach and monitoring process for the care of residents with existing wounds and those who are at risk for skin breakdown, to promote healing of existing pressure injuries and wounds. It is the policy of this facility that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing, with comprehensive assessment and plan of care. A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers. Skin impairments including pressure injuries should be assessed and documented weekly. 145852 Page 3 of 3