Health inspection·May 4, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to follow through with a wound referral for a worsening pressure ulcer, failed to timely reassess and identify worsening pressure ulcer, and timely treat new wounds for 1 of 2 residents reviewed for pressure ulcers in the sample of 16. This failure resulted in the worsening and infection of R12's pressure ulcer to the right ankle. Residents Affected - Few Findings: R12's medical record, New admission Information documents an admission date of 1/03/2023 with diagnoses including Hypertension, Edema (multifactorial component of Congested Heart Failure/Venous Stasis). R12's Minimum Data Set (MDS) dated [DATE], documents in Section C, Brief Interview for Mental Status (BIMS) score is 9, moderately impaired cognition, Section G, Functional Status, Extensive Assistance with one-person physical assistance with bed mobility, dressing, and personal hygiene, Extensive assistance with two-person physical assistance with transfers and toileting. R12's Nursing admission Assessment dated 1/03/2023 documents no skin issues noted. R12's Care Plan documents Moderate Risk for Pressure Ulcer per Braden Risk Assessment. Risk factors include impaired mobility and incontinence. Strengths include can turn self in bed, with a start date of 1/30/2023; Will have no new open areas caused by pressure or friction for the next 90 days, with a goal date of 4/30/2023; Interventions: Skin risk assessment: Braden Scale weekly x 4 weeks upon admission or readmission and then quarterly; Dietary consult to consider nutrition/hydration factors for treating related risk factors; Initiate extra calories, protein, vitamins as recommended; Initiate supplements as needed/recommended; See Physician's Order Sheet for orders; Apply house stock incontinent barrier cream to peri-area after every incontinent episode and as needed; Toilet/change brief when wet and upon rising, at bedtime, and after meals; Maintain clean, dry, wrinkle free linens with a start date of 1/30/2023. R12's Braden Assessments dated 2/12/23, 2/22/23, 3/1/23, and 3/8/23 all documents R12 is considered a high risk for pressure ulcers. R12's Progress Notes dated 2/15/2023, documents R12 has a stage II area to right outer ankle measuring 0.9 centimeters (cm) x 1.1cm, area scabbed over with no drainage or signs and symptoms of infection noted. R12's Physician's Orders dated 2/15/2023, documents 1. Cleanse Stage II area to right outer ankle (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 4 Event ID: 145964 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 145964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLeansboro Rehab & Hlth C Ctr 405 West Carpenter McLeansboro, IL 62859 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)