Health inspection·January 9, 2026

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 implement interventions for a resident's comprehensive pressure ulcer management strategy, including offloading a wound, mattress use, and nutritional supplement use. This applies to 1 resident (R123) reviewed for pressure injuries in a sample of 3. The findings include: R123's Face Sheet shows an admission date of 8/9/2025 with diagnoses including stage 4 pressure ulcer of the sacral region, dementia, and dysphagia. On 1/8/2026 at 1:40 PM, V26 (R123's Primary Physician) stated that his expectation is for facility staff to follow V24's (Wound Doctor) recommendations to ensure proper offloading, perform turning/repositioning, and administer nutrition supplements as ordered to support healing. V26 stated that failure to implement these interventions could impact functional status, wound healing, and overall health, including delayed healing, disease exacerbation, and increased risk of infection. R123's Kardex dated 1/8/2026, provided by V2 DON (Director of Nursing) showed that R123 requires total assistance for bed mobility and should be turned and repositioned in bed as necessary. V2 stated the Kardex system is intended to provide floor staff with resident instructions since they do not have access to residents' full care plans. Observation by surveyor from 10:36 AM to 12:50 PM on 1/6/2026, (either inside R123's room or within visual range of his door) noted the following staff activity and resident interactions:10:50 AM: V22 (CNA) entered briefly to set supplies down.10:55 AM: V22 returned to provide perineal care.11:00 AM: V2 (DON/Director of Nursing) observed outside room; did not enter.11:14 AM: V22 removed bagged dirty linen per V18 (R123's Niece) request.11:16 AM: V18 (R123's Niece) requested R123 be weighed via mechanical lift.11:20 AM: V21 (Nursing Supervisor) and V22 (CNA) positioned resident to prepare to obtain R123's weight per V18's request 11:31 AM: V23 (RN/Registered Nurse) had just finished checking R123's blood sugar as V24 entered for wound care.12:00-12:30 PM: Facility staff observed in hallway for tray service; V18 remained in R123's room and assisted him with lunch.12:50 PM: V18 (R23's Niece) stated R123 had not been positioned to offload his wound during this shift. Per V18, V24 (Wound Care Coordinator-WCC) stated manual turning is unnecessary due to R123's alternating-pressure mattress. On 1/7/2026 at 2:56 PM, V24 (WCC) stated that residents with alternating pressure mattresses do not require manual turning every two hours, as the mattress redistributes pressure and turning could cause pain or discomfort. V24 stated that such specialty mattresses take the place of manual turning, repositioning, and offloading. On 1/6/2026 at 10:36 AM, R123's specialty mattress was set for a 160 lb. (pound) person. The next day on 1/7/2026 at 2:30 PM and the day after that on 1/8/2026 at 12:40 PM, the mattress remained set for a 160 lb. person. R123's most recent weight was documented as 125.6 lbs. as of 1/2/2026. The (brand of mattress) Operation Manual for R123's mattress showed the mattress system is intended for prevention and treatment of pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. The Manual does not indicate that the mattress would replace wound offloading, manual turning, or repositioning interventions. On 1/7/2026 at 2:56 PM, V24 stated that floor nurses are expected to verify and adjust mattress weight Residents Affected - Few Page 1 of 3 145901 145901 01/09/2026 Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few settings each shift, and incorrect settings could affect pressure distribution and wound offloading, potentially worsening the injury. R123's POS (Physician Order Sheet) included an order to check and ensure mattress settings match resident weight each shift. R123's January 2026 POS (Physician Order Sheet) also included orders for (arginine powder) oral packet (a nutritional supplement to support wound healing) to be given three times per day, since admission in August. Review R123's EMAR (Electronic Medical Record) showed 75 doses of the (arginine powder) had been missed/not given and documented as not available or awaiting pharmacy delivery. V25's (Wound Doctor) 11/11/2025 wound assessment included wound deterioration as Lower back wound looks more pale. There are areas of undermining in the most inferior portion of the wound not present there before with watery drainage and pale granulation tissue. Assessment: patient wound base looks less organized with areas covered with granulation tissue now bare. Bone coverage is not great. There are areas of undermining that were not present before on his last visit. It is imperative that patient continue offloading this area. We should supervise that patient nutrition is high protein and minimal carbohydrate. On 1/8/2026 at 2:15 PM, V2 (DON) stated that it is her expectation that the facility's pressure ulcer prevention and management protocols be followed. V2 stated this includes ensuring residents receive ordered nutritional supplements; residents with impaired mobility are turned and repositioned every two hours regardless of mattress type; soiled dressings are removed; and new dressings are applied after appropriate wound cleansing. Per V2, failure to follow these interventions could result in infection and delayed wound healing. The facility's policy, Pressure Ulcer and Wound Prevention/Management Program (revised 9/30/2025), states that residents admitted with pressure ulcers or who develop them in-house must receive necessary treatment and services to promote healing, prevent infection, and prevent new sores when possible, and that wound care is managed by a team of healthcare professionals. 145901 Page 2 of 3 145901 01/09/2026 Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, the facility failed to provide double portions and nutritional shakes as ordered for a resident with diagnoses of pressure ulcer and malnutrition.This applies to 1 resident (R123) reviewed for following diets in a sample of 28 residents.R123's Face Sheet shows an admission date of 8/9/2025 with diagnoses including dehydration, diabetes mellitus, stage 4 pressure ulcer of the sacral region, dementia, and dysphagia. On 1/6/2026 at 10:36 AM, R123 was lying in bed with the head of the bed elevated attempting to drink a protein shake that family had brought in. V18 (R123's Niece) was at bedside. V18 assisted R123 as he was drinking. Per V18, she had repeatedly expressed concern to facility staff regarding R123's weight loss and stated that staff were not assisting with feeding, providing double portions, or supplying ordered nutritional supplements. V18 further noted that the protein shake at the bedside was family-supplied because the facility had not provided it, and that a milkshake ordered with breakfast was not provided that morning. On 1/6/2026 at 12:32 PM, R123 was observed during lunch with V18 assisting him. The tray did not include any supplements, and the beef entree was served as a regular portion, not double. On 1/7/2026 at 12:15 PM, R123 was observed for lunch again. No supplements were on the tray, and the spaghetti entree was served as a regular portion, not double. On 1/6/2026 at 12:35 PM, V22 (R123's CNA/Certified Nursing Assistant) stated there was no need to assist R123 with feeding because since he is independent. On 1/9/2026 at 9:20 AM, V18 (R123's Niece) stated that R123 was sent to the emergency room on 1/8/2026 and remains hospitalized with an admitting diagnosis of failure to thrive and severe malnutrition with muscle wasting. On 1/9/2026 at 9:36 AM, R123's status and admitting diagnosis were confirmed by the hospital-assigned RN (Registered Nurse). R123's Physician Order Sheet (POS) included a diet order for a NAS/LCS mechanical soft diet with Mighty Shakes (nutritional supplement) at breakfast and lunch with double portions, Med Pass (nutritional supplement) twice daily, and bedtime snacks, along with an order to notify the primary physician of significant weight changes. R123's Care Plan dated 12/26/2025 specifies that the resident requires partial to moderate assistance with eating due to ADL (Activities of Daily Living) self-care deficit. Interventions include that staff are expected to provide the diet as ordered, and the dietitian is to evaluate the resident and make diet change recommendations as needed. The facility's policy titled Interventions for Unintended Weight Loss (last revised June 2023) states, Individuals with unintended weight loss or insidious weight loss will be identified and monitored so that appropriate interventions can be implemented. Purpose: to address the needs of high-risk residents. 145901 Page 3 of 3