Health inspection·May 26, 2024

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 observation, interview, and record review, the facility failed to turn and reposition as identified in the care plan for one resident (R4) out of three residents reviewed who are identified as at risk for development of pressure injuries. Residents Affected - Few Findings include: On 05/25/2024 between 9:23 AM to 11:34 AM, no observations of staff helping R4 to turn and reposition. On 5/25/24 9:23 AM observed R4 lying on her bed, on her back, sleeping. On 5/25/24 11:34 AM observed R4 laying on her bed, laying on her back, wearing a yellow gown. R4 states that she needs assistance with getting cleaned up and to turn to different positions because R4 states that she is unable to do it by herself. R4 states that her skin has kind of cleared up. R4 states that she used to have a lot of blisters. R4 states that the last time she was changed was during the night shift. R4 states that she has not been moved or repositioned since the last time they changed her in the night shift. R4 states that staff have not been in her room to ask her if she wanted to be turned or reposition. R4 states that sometimes R4 has pain or pressure on her neck and back, because R4 states that she slides down at times due to the mattress and position that she is in and R4 states that when she tries to lift her head up, her neck feels scrunched up. R4 states that causes her to have discomfort. On 5/25/2024 12:26 PM V6 (certified nursing assistant) states that R4 is total care, but V6 states that R4 can tell you everything that she wants and needs. V6 states it is important to turn and reposition residents to prevent skin breakdown, and bed wounds and bed sores. R4's Face sheet documents that R4 was admitted to the facility on [DATE] who has diagnoses not limited to: Type 2 Diabetes Mellitus, peripheral vascular disease, diaper dermatitis, morbid (severe) obesity due to excess calories, and low back pain. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R4 is cognitively intact. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has a rolling left and right mobility score of 1 out of 6 indicating R4 is dependent. R4 recent Braden scale for predicting pressure sore risk assessment dated [DATE] documents R4 Page 1 of 2 145888 145888 05/26/2024 Alden Estates of Northmoor 5831 North Northwest Highway Chicago, IL 60631

F 0686 scored 14.0 indicating R4 is at moderate risk for pressure injury. Level of Harm - Minimal harm or potential for actual harm R4's care plan document's in part R4 has actual skin alteration due to impaired circulation, decreased mobility, dependence on ADLs (activities of daily living), incontinence and other underlying comorbidities. Interventions not limited to turn and reposition every two hours and as needed. Residents Affected - Few Facility document, dated 03/10/2022, titled Bed Mobility documents in part, bed mobility refers to activities provided to improve or maintain the resident's self-performance .turning side to side. These activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record. 145888 Page 2 of 2