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
(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:
145967
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
145967
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Elevate Care Country Club Hill
18200 South Cicero Avenue
Country Club Hills, IL 60478
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145967
If continuation sheet
Page 2 of 2
