Health inspection·January 31, 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 ensure a physician-ordered negative pressure wound treatment system (wound vac) was placed for a resident with stage 4 pressure ulcers and failed to ensure a resident's stage 4 pressure ulcer was covered. Residents Affected - Few This applies to 2 of 3 residents (R1, R2) reviewed for pressure ulcers. The findings include: 1.R1's Face Sheet showed she is a [AGE] year-old resident who was initially admitted to the facility on [DATE]. R1's progress notes showed she was sent to the hospital on 1/17/2024 to facilitate antibiotic treatment due to osteomyelitis and the lack of progressive healing of her wounds. R1's diagnoses include cerebral palsy, severe protein-calorie malnutrition, anorexia nervosa, pressure ulcer of sacral region stage 4, pressure ulcer of right buttock, stage 4 osteomyelitis, and adult failure to thrive. R1's 1/11/2024 Minimum Data Set (MDS) showed her cognition is moderately impaired. R1's Resident Face Sheet showed she was re-admitted to the facility on [DATE]. R1's January 2024 Physician Order Report showed 1/21/2024 orders for wound vac placement with negative pressure of 125 continuously to her right buttock and sacrum, with special instructions of when seal is broken disconnect wound vac and apply a wet to moist dressing and cover with a dry dressing. The Report showed these orders were discontinued on 1/24/24 (during the survey), then restarted on 1/29/24. On 1/23/2024 at 11:53 AM (two days after R1's re-admission), R1 was in bed. R1 had severe contractures to all her extremities and was unable to move herself. Her wound vac machine was on top of her nightstand, turned off, and not attached to her wounds. Two boxes of available wound vac supplies were on R1's floor. On 1/24/2024 at 10:15 AM (three days after R1's re-admission), R1 was in bed and the wound vac machine was still turned off on her nightstand and still not in use. V5 (Registered Nurse/Wound Nurse from a sister facility) came to do the wound care. V5 removed a dressing that had been in place. On 1/24/24 at 2:25 PM, V6 (Wound Physician) stated if the wound vac seal is broken, or the wound vac is not available, there are alternate orders. V6 stated the wound vac was ordered for controlling drainage and helping with wound granulation. V6 stated R1 should have the wound vac hooked up and functioning and should not be without it for more than two hours. (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: 145901 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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)