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 interview and record review the facility failed to notify the physician when a resident developed an
unstageable pressure ulcer and failed to notify the physician and implement a new treatment order after a
change in a pressure ulcer for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 8.
Residents Affected - Few
The findings include:
R1's Wound Assessment Details Report dated 2/3/24 shows that an unstageable pressure ulcer with
necrosis measuring 3 centimeters (cm) x 3 cm was identified on 2/3/24. The wound had a moderate
amount of serous drainage and no odor.
R1's Nursing Notes dated 2/3/24 at 6:40 PM shows, Noted a pressure injury on [R1's] sacrum. Cleansed
with NS (normal Saline), pat dried, and applied bordered foam Notified and explained treatment plan to
POA
R1's Treatment Administration Record (TAR) for February shows an order entered on 2/3/24 for, Treatment:
Sacrum: Cleanse with NS, pat dry, and apply bordered foam every day shift every 3 days(s) for wound
treatment.
R1's Electronic Medical Record does not document that R1's physician was notified of the new pressure
ulcer.
On 2/14/24 at 2:02 PM, V6 (Wound Registered Nurse) said that he found R1's wound on 2/3/24. V6 said
that the wound had eschar and some drainage but did not have an odor and was not painful. V6 said that
he put in an order for a foam dressing to be applied and changed on Monday, Wednesday, and Friday until
she saw the wound physician for further treatment. V5 (Wound Director) said that he was called to the room
on 2/5/24 to look at the wound. V5 said that he took the dressing off and noticed an odor, so he applied
Dakin's solution (antiseptic wound cleaner) and wanted the dressing changed daily using Dakin's until she
saw the wound physician.
On 2/14/24 at 2:38 PM, V6 said that he did not notify R1's physician of her new pressure ulcer. V6 stated,
We do not call the doctor all the time if a resident develops a pressure ulcer. We can use our judgement
until the resident is seen by the wound physician. We only call them if there is an issue like we think it is
infected or something.
R1's EMR does not document that R1's physician was notified when there was a change to R1's wound
(odor) and no new orders were placed on R1's TAR on 2/5/24.
(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:
145923
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
145923
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Warren Barr North Shore
2773 Skokie Valley Road
Highland Park, IL 60035
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)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R1's Wound Evaluation and Management Summary dated 2/8/24 shows that the wound physician saw R1,
and the pressure wound on her sacrum was classified as a stage 4 pressure ulcer measuring 3.6 cm x 4
cm x 1 cm. R1's dressing treatment plan was for Dakin's-soaked gauze wet to moist dressing daily. Under
additional wound details it shows, Unavoidable and unpredictable wound secondary to decline in overall pt
(patient) condition Pt has been sharply declining in all faculties including PO (by mouth) intake,
mobility/activity, and mental acuity which no doubt instigated the wounds development Was found to have
developed an open wound on her sacrum on Saturday; The wound was already fairly large and necrotic
with odor, which appeared in only 1 day; Dakin's dressing was started immediately, and family was notified
that day .
R1's February 20245 TAR shows that the daily dressing change using Dakin's solution was not ordered
until 2/10//24 (7 days after wound was identified). R1's TAR and Nursing Notes do not show that she had
received any dressing changes using Dakin's solution or that it was done daily since the wound was first
identified. R1's TAR shows that treatment of: cleanse with NS, pat dry, and apply bordered foam dressing to
her sacrum wound was performed on 2/3, 2/5, 2/6, and 2/9/24.
The facility's Skin Care Treatment Regimen Policy revised on 7/28/23 shows, Charge nurses must
document in the nurse's notes and/or the Wound Report form any skin breakdown upon assessment and
identification. Furthermore, topical skin treatment must be obtained from the patient's physician .TAR
Nursing Documentation: Routine wound care completed by wound care nurse or designee Topical
Treatment Protocol: Unless otherwise indicated by the attending physician stage 3 and 4 Cleaned wound
Base: Ca Alginate, Hydrocolloid Gauze/gel daily, xeroform gauze. Necrotic areas: Santyl Ointment daily .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145923
If continuation sheet
Page 2 of 2
