Inspection·June 7, 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 observation, interview, and record review, the facility failed to ensure pressure related skin changes were reported and assessed, and interventions were implemented for 1 of 3 residents (R5) in the sample of 11 reviewed for pressure injuries. Residents Affected - Few The findings include: R5's Minimum Data Set (MDS) dated [DATE] shows R5 is cognitively intact, requires extensive assistance with bed mobility and transfers, and is at risk of developing pressure ulcers/injuries. R5's current care plan provided by the facility showing an admission date of 1/23/23 shows R5's diagnoses include, but are not limited to, protein malnutrition, failure to thrive, chronic kidney disease, hypertension, and hypothyroidism. R5's same care plan shows nursing is to observe for signs of skin irritation and/or breakdown and report to the physician, nursing is to perform and document skin check, notify the physician and treatment team of any integumentary (skin) changes, encourage proper positioning and relief on pressure points and time off her back when in bed. R5's last Skin Assessment was documented on 5/27/23 and showed her skin was WDL (within defined limits) and she had a low air loss mattress in place There is no mention of any redness or skin changes to R5's spine. On 6/5/23 at 10:15 AM, R5 was lying on her back on top of her bed covers with a pillow under her knees. R5 did not have a low air loss mattress on her bed. R5 said she was told she had a red area on her spine and they would need to keep an eye on it. On 6/5/23 at 10:22 AM, V6, Certified Nursing Assistant (CNA), assisted R5 to allow observation of her spine. R5's spine was reddened over an area where her spine was curved and the bones of her spine were very prominent. V6 said, It's just some redness. On 6/5/23 at 1:53 PM, V2, Director of Nursing (DON)/Wound Care Nurse, said the CNAs report any skin changes to the nurse, the nurse does a head to toe assessment of the resident's skin and notifies her of the skin change. V2 said the nurse can look at their flow sheet and will implement treatment based on the flow sheet. V2 said not all risk factors for a resident to be a high risk of skin breakdown are captured in the Braden scale. Other conditions can trigger staff to implement the Pressure Injury Prevention Protocol. Skin breakdown can develop rapidly with residents who are thin, elderly with poor nutrition with very little tissue to cover the bony prominences and decreased mobility. On 6/6/23 at 09:01 AM R5 was lying on her back, asleep in bed with no low air loss mattress on her bed. (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: 146014 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 146014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Harvard Hospital Care Center 901 South Grant Harvard, IL 60033 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)