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: Page 1 of 3 145977 145977 01/22/2025 South Shore Rehabilitation 2425 East 71st Street Chicago, IL 60649

F 0686 Multiple diagnoses which include but are not limited generalized muscle weakness and reduced mobility. Level of Harm - Minimal harm or potential for actual harm Pressure Ulcer Risk assessment dated [DATE] shows that R3 is at risk for pressure ulcer. Residents Affected - Some MDS section M dated 11/30/24 states that R3 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 8/3/21 states: R3 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. R4's records show the following: Multiple diagnoses which include but are not limited generalized muscle weakness and reduced mobility. Pressure Ulcer Risk assessment dated [DATE] shows that R4 is at risk for pressure ulcer. MDS section M dated 11/3/24 states that R4 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 11/9/22 states: R4 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. R5's records show the following: Multiple diagnoses which include but are not limited generalized muscle weakness and reduced mobility. Pressure Ulcer Risk assessment dated [DATE] shows that R5 is at risk for pressure ulcer. MDS section M dated 10/25/24 states that R5 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 4/18/24 states: R5 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. R6's records show the following: Multiple diagnoses which include but are not limited generalized muscle weakness and difficulty walking. Pressure Ulcer Risk assessment dated [DATE] shows that R6 is at risk for pressure ulcer. MDS section M dated 11/25/24 states that R6 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 1/13/20 states: R6 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. 145977 Page 2 of 3 145977 01/22/2025 South Shore Rehabilitation 2425 East 71st Street Chicago, IL 60649

F 0686 R7's records show the following: Level of Harm - Minimal harm or potential for actual harm Multiple diagnoses which include but are not limited Dementia and Difficulty Walking. Pressure Ulcer Risk assessment dated [DATE] shows that R7 is at risk for pressure ulcer. Residents Affected - Some MDS section M dated 1/3/25 states that R7 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 7/3/23 states: R7 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. Facility's policy titled Pressure Ulcer and Wound Prevention/Management Program with latest revision date 12/5/06, states under Purpose: To identify residents who are at risk for pressure ulcers and skin breakdown, and to prevent pressure ulcers and skin breakdown. #7 states: The residents plan of care is audited at least quarterly or more frequently when change in condition occurs by the interdisciplinary team. Each intervention is analyzed to determine if the intervention is still appropriate and is actively provided. Interventions are added or changed as necessary to prevent further breakdown and promote healing as necessary. #8: The preventative measures from residents at risk will be implemented based on Braden Score and as deemed necessary based on clinical condition by the interdisciplinary team. 145977 Page 3 of 3