Health inspection·July 25, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a treatment plan for (R4) who was identified as very high risk for skin break down, admitted with an opening on the penile shaft, excoriation on the penile head/tip with the penile prosthesis in an erectile position for twenty-two days. This failure resulted in R4 sustaining a facility acquired full thickness, moisture associated skin dermatitis (MASD) measuring 8.00 centimeters (cm) x 3.00 (cm) x 0.10 (cm) (L x W x D) for one of three reviewed for wound care in a sample size of ten. Residents Affected - Few Findings Include: On 7/19/24 at 12:58PM, V6 (treatment nurse) stated, MASD is caused by moisture (urine, stool, sweat and or body fluids) which would cause a break in skin due to repetitive movements or friction. R4 was admitted with a penile implant that was fixed and erect. It would not go down. We had to ensure his adult brief was in place a certain way to prevent friction. V6 stated, she was not sure what that certain way R4 adult brief was place. R4 started to have skin break down to the penis, the doctor was notified. R4 needed to have surgery to have the rod removed. V6 stated, she was not aware of what type of penile implant R4 had, how to deflate the implant, R4 did not go out on any appointment or to the hospital for the implant and was discharged before we could establish anything. On 7/19/24 at 2:45pm, V9 (ADON/assistant director of nursing) stated, R4 did not have a treatment in place upon admission for his penis. V9 stated, R4 had a photo of his penis on admission that showed an opening on the shaft and excoriation on the head/tip. V9 stated, R4 should have had a treatment put in place, the doctor should have been notified and the site should have been measured upon admission. R4 had a treatment put in place on 3/11/24. On 7/24/24 atn3:41pm, V38 (wound doctor) stated, he saw R4 once or twice. Full thickness is the third layer of skin loss. V38 stated, the facility should have been monitoring R4 for any type of skin break down. R4 needed surgery. V38 stated, he does not have any more information on R4. Hospital referral paperwork dated 2/14/2011 documents: R4 prosthesis left in the semirigid position. Nursing note dated 3/11/24 documents: R4 has a pressure injury noted to his penis. Physician order sheet date 3/11/24 document: Wound care: Penis clean with normal saline and apply zinc. Wound assessment dated [DATE] documents: R4 had a facility-acquired moisture associated skin Page 1 of 2 145967 145967 07/25/2024 Elevate Care Country Club Hill 18200 South Cicero Avenue Country Club Hills, IL 60478

F 0684 Level of Harm - Actual harm Residents Affected - Few damage. Classification: Incontinence. Stage: Full thickness. Size (cm) 8.00 x3.00 .0.10 (L x W x D). Area 24.00cm. Air loss mattress noted in place. Resident has a penile prosthesis that is fixed, erected is incontinent of bowel and bladder. Wound doctor visit dated 3/14/24 documents: wound#5. Penis is a partial thickness abrasion and had received the status of not healed. Initial wound encounter measurements are 2cm length x 2 cm width x 0.1 cm depth, with an area of 4 square cm. scant amount of sero-sanguineous. According to the national pressure injury advisory panel a stage 3 Pressure Injury is defined as a Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Pressure Injury and Skin Condition assessment dated [DATE] documents: to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. 145967 Page 2 of 2