Health inspection·January 11, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to complete wound care as ordered and document wound descriptions/observations in 2 of 3 residents (R1, R2) reviewed for wound care in the sample of 3. Residents Affected - Few Findings include: 1. On 1/9/24 at 8:40 AM, R2 was observed in her room, up in the wheelchair. R2 had dressings in place to her bilateral lower extremities (BLE). The dressings were undated, both loose and the wounds were exposed. The dressings were soiled with yellow and bloody drainage. Areas to the BLE that were visible, were dry with scaly skin, red and swollen. R2 stated she has pain everywhere and her BLE itch. R2 stated she has seen a wound care doctor and wants to know what is causing the wounds. R2 stated they change her dressings every day but only once a day, regardless of if they are soiled or need changed. On 1/9/24 at 11:00 AM, R2's BLE were observed with V3, Assistant Director of Nurses, (ADON), and V6, Registered Nurse (RN), with the following noted: the old undated dressings were removed and had large amounts of yellow and red drainage on them. R2's BLE were red, inflamed, had several open bloody scratches and several fluid filled blister areas. R2's Face Sheet, undated, documents R2 has the following diagnoses: Lymphedema, Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes, Chronic Pain, Obesity, Hypertension (HTN), Peripheral Vascular Disease (PVD), Chronic Kidney Disease, Heart Failure, Hyperlipidemia and Hypothyroidism. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact and has open lesions. R2's Care Plan, dated 9/27/23, documents R2 is at risk for skin impairment related to aging/disease process, decreased mobility, diabetes, diuretic therapy, edema, fragile skin, impaired mobility, incontinence, non-compliance with turning and repositioning, Lymphedema, non-compliance with showers and personal hygiene. R2 has interventions to keep skin clean and dry, complete preventative treatment as ordered and Lymphedema boots to BLE per therapy. R2's Physician Order Sheet (POS), documents the following order, dated 9/27/23, Triamcinolone Acetonide External Cream 0.1 %. Apply to BLE topically one time a day for preventative. R2's Treatment Administration Record (TAR), documents the following: the Triamcinolone was not administered 3 times in November 2023, 12 times in December 2023 and 1 time in January 2023. R2's Skin Reports, dated 12/14/23, 12/21/23, 12/28/23 and 1/4/24, fail to document a Page 1 of 3 145928 145928 01/11/2024 Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650

F 0684 description/observation of R2's BLE wounds. Level of Harm - Minimal harm or potential for actual harm R2's Progress Note, dated 1/5/24 at 10:22 PM by V9, Nurse Practitioner, documents the following: R2 has chronic BLE Lymphedema, followed by Lymphedema clinic. R2 has orders for Lymphedema boots to be worn at all times to bilateral lower extremities, however, she refuses. Today, R2 has multiple scratches and abrasions to her BLE with dried blood. R2 reports she has been itching her legs, causing wounds. Will request in house wound physician to evaluate. R2 is encouraged and educated to elevate her legs frequently. R2 reports she is barely able to transfer herself from her bed to her wheelchair and reports chronic generalized weakness. Throughout the day, but she prefers to sit in her wheelchair most of the day, her legs in a dependent position. R2 has Triamcinolone Acetonide External Cream 0.1 % to be applied daily to her BLE. She is waiting for Velcro BLE wraps to be approved by her insurance. There was no other documentation in R2's progress notes regarding R2's wounds. Residents Affected - Few 2. On 1/9/24 at 8:45 AM, R1 was observed in bed, with dressings in place to the right lower extremity (RLE) down to the right foot. The dressing was undated. R1's Face Sheet, undated, documents R1 has the following diagnoses: COPD, Acute/Chronic Respiratory Failure, Type 2 Diabetes, Obesity, HTN, Atrial Fibrillation, Congestive Heart Failure, Hyperlipidemia, PVD and Non-Pressure Chronic Ulcer of the Lower Leg. R1's MDS, dated [DATE], documents R1 is cognitively intact, has two venous/arterial ulcers and open lesions. R1's Care Plan, dated 7/17/23, documents R1 has skin impairment of the right heel, right lower medial leg, right anterior leg, right dorsal second toe and right dorsal foot related to aging/disease process, CHF (Congestive Heart Failure), Diabetes, fragile skin, impaired mobility, incontinence, non-compliance with turning and repositioning and vascular insufficiency. R1 has interventions to complete treatments as ordered. R1's POS, has an order dated 12/8/23, for Balsam Peru Castor Oil External Ointment. Apply to bilateral lower legs topically one time a day for wounds. R1's TAR documents the [NAME]-castor oil external ointment was not applied 10 times in December 2023. On 1/9/24 at 11:00 AM, V3, ADON/Wound Nurse, stated R2 was admitted to the facility with Lymphedema, and they are applying Triamcinolone daily. V3 stated hey have been wrapping R2's BLE with gauze roll because R2 itches and picks at it. V3 stated R2 was referred to a Lymphedema clinic and they ordered Lymphedema boots, and they just sent the information to R2's insurance to get them approved and ordered. V3 stated the nurse practitioner wanted to continue with the triamcinolone daily until the boots come in. V3 stated R2 will follow up again with the Lymphedema clinic once the boots are in. V3 stated R2 has not been ordered any antibiotics for infection. On 1/10/24 at 10:20 AM, V2, Director of Nurses (DON), stated if a dressing is soiled, it should be changed. V2 stated once a wound is identified, they contact the physician, follow the physician orders and document on the wound weekly. The Pressure Injury and Skin Condition Assessment policy, dated 11/2012, documents the purpose is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, 145928 Page 2 of 3 145928 01/11/2024 Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pressure injuries and other ulcers and assuring interventions are implemented. A wound assessment for each identified open area will be completed and will include site location, size, stage of pressure ulcer, odor, drainage, and description. Dressings which are applied to pressure ulcers, skin tears, wounds, lesions, or incisions shall include the date of the licensed nurse who performed the procedure. Dressings will be checked daily for placement, cleanliness, and signs and symptoms of infection. Physician ordered treatments shall be initiated by the staff on the electronic TAR after each administration. A licensed nurse shall observe the condition of the wound daily or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes. 145928 Page 3 of 3