Health inspection·January 22, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions as stated in the care plan for residents at risk for pressure ulcers. This failure has the potential to affect six residents (R2, R3, R4, R5, R6, and R7), reviewed for wheelchair cushions as a pressure ulcer prevention intervention for residents. Residents Affected - Some Findings include: On 1/15/25 at 11:50am during observation of residents in the fourth-floor dining room, R2 and R3 were observed sitting in the wheelchair without pressure relieving cushion. At 12:13pm, both residents were still in the wheelchairs without cushions. At this time, V9 (CNA/Certified Nurse Assistant) who was with the residents at the time was notified and stated that she (V9) would ask Restorative. V9 stated that residents need the cushions in the wheelchair to prevent wounds. V3 (Unit Manager) also stated that she (V3) would find cushions for the wheelchairs immediately she finishes assisting the resident with lunch. On 1/15/25 at 12:18pm during observation of residents in the third-floor dining room, R4, R5, R6, and R7 were observed sitting in the wheelchair without pressure relieving cushion. At 12:27 pm, all 4 residents were still in the wheelchair without cushion. At this time, V12 (Wound Care Technician) was notified and stated, I am the Wound Care Tech. They need cushions in the wheelchairs to keep the buttocks from breakdown and from having pressure ulcer. I will put the cushions in the wheelchair. On 1/15/25 at 1:00pm, V13 (Wound Care Nurse) stated, Residents' wheelchairs should have cushions to prevent pressure ulcers. We will in-service them. R2's records show the following: Multiple diagnoses which include but are not Limited Mobility. Pressure Ulcer Risk assessment dated [DATE] shows that R2 is at risk for pressure ulcer. MDS (Minimum Data Status) section M dated 11/3/24 states that R2 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 12/16/20 states: R2 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. R3's records show the following: (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 3 Event ID: 145977 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street Chicago, IL 60649 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)