Health inspection·July 2, 2023

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 interview and record review, the facility failed to follow their protocols and have interventions in place to prevent a resident admitted with intact skin from developing a pressure ulcer. This failure applied to one (R2) of one resident reviewed for pressure ulcers, and resulted in R2 developing an unstageable pressure ulcer to the sacrum that required surgical debridement. Residents Affected - Few Findings include: R2 is an [AGE] year-old female, originally admitted on [DATE], and has diagnoses including but not limited to: metabolic encephalopathy, hypertensive chronic kidney disease, and dementia. Minimum Data Set (MDS) dated [DATE], documents R2 needs extensive assistance of two staff members for bed mobility and transfer, R2 needs extensive assistance of one person for locomotion in wheelchair, dressing, toileting, and personal hygiene. Section M indicates R2 is at risk for pressure ulcers. Record Review from a local emergency room reads in part: on 12-19-2023, R2 was identified with a pressure injury mid sacrum. (R2) presents with unstageable pressure injury to sacrum and area of increased dusky tissue on right lateral lower buttock which, upon testing, is partially blanching. On 12-21-2022, Initial Nutrition Assessment reads: skin integrity: stage 3 left sacrum pressure injury, unstageable mid sacrum pressure injury. Increased nutrient needs (protein) related to increased demand for nutrient secondary to loss of skin integrity, delayed wound healing or pressure injury. On 12-23-2022, R2 had a sharp debridement to the sacrum area. On 6-30-2023 at 2:55pm, V5 (R2's family member) said, I told V4 (Registered Nurse) a week after (R2) was admitted that I noticed a small wound to (R2's) buttocks. I asked for the doctor to be contacted and requested a treatment to avoid it getting worse. The following day I checked with V4 again, and the nurse told me no treatment was obtained. On 12-19-2022, (R2) went to the hospital; the nurse told me (R2) had a bedsore in the coccyx area when she arrived at the Emergency room. On 6-30-2023 at 11:00am, V4 (Registered Nurse) said, I am the regular nurse for the morning shift. (R2) was in my set. (R2) was alert and oriented but confused. (R2) was dependent on all ADL's, assistance with turning, incontinence care, feeding. I can see in the electronic medical record that (R2) was admitted to the facility on [DATE]. According to the assessment, (R2) did not have any open skin; it was documented old scarring from history of pressure ulcer to the left buttocks. On 12-19-2022, (R2) was sent out to the hospital because we received some abnormal laboratory results. BUN (Blood Urea Nitrogen) was 79, normal level is 7-23 mg/dL and Sodium (Na) 150 normal level is 133 - 148 mmol/L. (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: 145984 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 145984 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden North Shore Rehab & Hcc 5050 West Touhy Avenue Skokie, IL 60077 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)