Inspection·March 22, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm 3. On 3/22/24 at 9:51 AM, R6 was observed lying in bed. A gauze dressing was observed to his sacrum. Residents Affected - Few R6's Wound Physician Progress note dated 3/12/24 documents a stage 4 pressure wound to the sacrum measuring 2.1 cm x 2.0 cm x 0.2cm. Treatment orders include apply calcium alginate with silver and foam dressing daily. Peri-wound treatment apply antifungal and zinc daily. R6's Treatment Administration Record (T.A.R.) dated March 2024 shows orders to clean with dakins and betadine, apply calcium alginate with santyl anchor with 4x4 gauze, apply zinc around wound, apply border patch every night shift. A second treatment order wound care: cleanse with 1/4 dakins solution cover with leptospermum honey soaked with calcium alginate, gauze island with border foam daily and apply zinc around peri wound daily at 5:00 AM. The T.A.R. shows two different treatments and both do not show the prescribed treatment as ordered. The T.A.R. shows both treatments are signed off daily. Based on observation, interview, and record review, the facility failed to ensure pressure ulcer treatments and/or prevention interventions were implemented and/or completed, as ordered, for 3 of 3 residents (R3, R6, and R8) reviewed for wounds in the sample of 13. The findings include: 1. On 3/22/24 at 9:54 AM, R8 was lying in bed on a regular mattress. No low air loss mattress was in place for R8. R8 said staff turn her when they change her pamper, but was not sure how often she is changed. R8 said she has a wound to her bottom, but doesn't know if there is a dressing. On 3/22/24 at 10:11 AM, R8 said, Tell them to come change me. On 3/22/24 at 10:05 AM, V4, Licensed Practical Nurse (LPN), said R8 has a pressure ulcer to her sacrum and R8's wound care is ordered daily on the night shift, and as needed, if it becomes soiled or removed. V4 said she rounds with the wound care physician each week. V4 assisted R8 to turn to her left side. R8 had a dressing in place to her sacrum which was dated 3/21/24 (the day prior to this investigation). V4 said she needs to change R8's dressing because it is soiled. R8's brief and dressing were both saturated. On 3/22/24 at 10:24 AM, V20, Certified Nursing Assistant (CNA), said R8 has not been changed since she began her shift at 7:00 AM. V20 said residents are supposed to be changed and repositioned every two hours. On 3/22/24 at 1:25 PM, V4 said she rounds with the wound care doctor and them puts the wound (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: 146013 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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)