Health inspection·January 14, 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 four residents (R9, R10, R11, and R12), reviewed for wheelchair cushions as a pressure ulcer prevention intervention for residents. Residents Affected - Some Findings include: On 1/8/25 at 12:02pm during observation of residents in the third-floor dining room, R9, R11 and R12 were observed in the dining room sitting in the wheelchair without pressure relieving cushion. Again at 12:15pm, all 3 residents were still in the wheelchairs without cushions. At this time, V5 (CNA/Certified Nurse Assistant) who was with the residents at the time was notified and stated that (V5) would ask Restorative. On 1/8/25 at 12:07pm during observation of residents in the second-floor dining room, R10 was observed in the dining room sitting in the wheelchair without pressure relieving cushion. Again at 12:25pm, R10 was still in the wheelchair without cushion. At this time, V14 (CNA/Restorative Aide) was notified and V14 stated I am the Restorative Aide. I just got here. I will go and get a cushion now. I usually go round and make sure everyone has a cushion in the wheelchair to prevent pressure sore. On 1/8/25 at 1:02pm, V2 (Assistant Director of Nursing) stated Residents should have cushions in the wheelchair to prevent pressure ulcers; We will in-service them. On 1/8/25 at 1:10pm, V13 (Wound Care Nurse) stated: Residents' wheelchairs should have cushions to prevent pressure ulcers. R9's records show the following: Face sheet shows diagnoses which include but are not limited Dementia. Pressure Ulcer Risk assessment dated [DATE] shows that R9 is at high risk for pressure ulcer. MDS (Minimum Data Status) section M dated 12/23/24 states that R9 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 7/7/23 states: R9 is at risk for impaired skin integrity. Intervention states to use pressure relieving chair cushion. Page 1 of 4 146001 146001 01/14/2025 Aperion Care International 4815 South Western Ave Chicago, IL 60609

F 0686 R10's records show the following: Level of Harm - Minimal harm or potential for actual harm Face sheet shows diagnoses which include but are not limited Generalized Muscle Weakness. Pressure Ulcer Risk assessment dated [DATE] shows that R10 is at moderate risk for pressure ulcer. Residents Affected - Some MDS section M dated 12/23/24 states that R10 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 7/15/24 states: R10 is at risk for impaired skin integrity. Intervention states to use pressure relieving chair cushion. R11's records show the following: Face sheet shows diagnoses which include but are not limited Generalized Muscle Weakness. Pressure Ulcer Risk assessment dated [DATE] show that R11 is at moderate risk for pressure ulcer. MDS section M dated 12/24/24 states that R11 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for bed. Care plan dated 9/20/23 states: R11 is at risk for impaired skin integrity. Intervention states to use pressure relieving chair cushion. R12's records show the following: Face sheet shows diagnoses which include but are not limited protein calorie malnutrition and chronic kidney disease. Pressure Ulcer Risk assessment dated [DATE] shows that R12 is at high risk for pressure ulcer. MDS section M dated 10/18/24 states that R12 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for bed. Care plan dated 5/19/23 states: R12 is at risk for skin breakdown. Intervention states to use pressure relieving/reducing cushion so protect the skin while up in chair. Facility's policy titled Pressure Ulcer Prevention with latest revision date 1/15/18 states under Purpose: To prevent and treat pressure injuries. #10 states: Use pressure reducing pads in chairs (all types) to protect bony prominences for residents identified as moderate/high/severe risk. 146001 Page 2 of 4 146001 01/14/2025 Aperion Care International 4815 South Western Ave Chicago, IL 60609

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed implement fall prevention interventions as stated in the care plans and follow facility fall prevention policy for three (R3, R4 and R5) of four residents reviewed for accidents on the sample list of 13. Findings include: On 1/6/25 at 11:25am in the second-floor dining room, R3 was observed sitting in the wheelchair in the day room wearing red socks with white patterns that are all smooth on the bottom. Again at 11:45am, R3 still had the same pair of socks on. The surveyor notified V4(CNA/Certified Nurse Assistant). V4 stated I know residents should wear proper shoes or non-skid socks. (R3) should wear non-skid socks since she is not wearing shoes. I will ask someone to get the nonskid socks. On 1/6/25 at 11:10am in the third-floor dining room, R4 and R5 were both observed. R4 was in the wheelchair with grey socks that are smooth on the bottom. R5 also was in the wheelchair with grey socks that are smooth on the bottom. V5(CNA/Certified Nurse Assistant) confirmed the names of both R4 and R5. Again on 1/6/25 at 11:35am, R4 and R5 still had the same socks on. V6 (CNA) was notified. V6 stated maybe the socks were brought in by the residents' families. V6 added I will find non-skid socks for both of them. V6 explained that the socks need to be non-skid to prevent falling. On 1/6/25 at 11:45am, V3 (Restorative Nurse) erroneously stated It is not mandatory for residents in the wheelchair to have non-skid socks, as long as they don't walk. On 1/6/25 at 12:15pm, V2 (Assistant Director of Nursing/ADON) stated I just came to correct what the restorative nurse told you. The restorative nurse is kind of new. All residents should have nonskid socks or proper fitting shoes to prevent falling. I in-serviced her about it. I in-serviced the other staff also. V2 later presented a record of in-service signed by nursing staff, dated 1/6/25, that says All residents should have on proper footwear which should include shoes and nonskid socks when up. R3's records reviewed are as follows: Fall Risk assessment dated [DATE] states that R3 is at risk for falls. MDS (Minimum Data Set) dated 10/1/24 shows that R3's mobility device is wheelchair. Care plan dated 2/2/23 states in part that R3 is at risk for falls. Intervention says to ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. BIMS Score dated 1/7/25 is 12 out of 15(Mild Cognitive Impairment). R4's records reviewed are as follows: Fall Risk assessment dated [DATE] states that R4 is at risk for falls. 146001 Page 3 of 4 146001 01/14/2025 Aperion Care International 4815 South Western Ave Chicago, IL 60609

F 0689 MDS dated [DATE] shows that R4's mobility device is wheelchair. Level of Harm - Minimal harm or potential for actual harm Care plan dated 6/7/24 states in part that R4 is at risk for falls and a history of recurrent falls and remains at risk for new falls, related to poor safety awareness. Residents Affected - Few BIMS Score dated 10/18/24 is 4 out of 6 (Severe Cognitive Impairment). R5's records reviewed are as follows: R5 had unwitnessed falls on 2/22/24, 2/24/24, 3/9/24, and 6/3/24. Fall Risk assessment dated [DATE] states that R4 is at risk for falls. MDS dated [DATE] shows that R5's mobility device is wheelchair. Care plan dated 12/24/22 states in part that R5 should have appropriate footwear when out of bed. BIMS Score dated 1/3/25 is 6 out of 15(Severe Cognitive Impairment). Facility's Fall Prevention Program with latest review date 11/21/17 states in part: To assure the safety of all residents in the facility when possible. This program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary Footwear will be monitored to ensure the residents have proper fitting shoes and/or footwear is nonskid. 146001 Page 4 of 4