Health inspection·June 6, 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 develop/implement interventions for 1 of 3 residents reviewed for pressure ulcers in the sample of 4. Residents Affected - Few Findings include: R2's face sheet documents an admission date of 4/27/2025. Diagnosis include Hypertensive Heart Disease with Heart Failure, Human Immunodeficiency Virus, Chronic Obstructive Pulmonary Disease, Acute Myocardial Infarction, Cerebral Infarction. On 6/5/2025 at 8:15AM V3, Assistant Director of Nursing, ADON, stated R2 does not have any skin issues. On 6/5/2025 at 8:30AM V3 stated, We just did a skin check on R2 and she does have a new area to her left buttock. We just found it this morning. She recently came back from the hospital. I talked to the nurse who did R2's admission assessment and he denied any skin issues. She was in the hospital quite a while. On 6/5/2025 at 9:30AM V3, Assistant Director of Nursing, ADON, and V4, Licensed Practical Nurse, LPN, performed skin check to R2. Dime size open reddened area noted to left buttock. R2's Minimum Data Set, MDS, dated [DATE] documents R2 has no cognitive deficits. R2's MDS dated [DATE] documents R2 has no unhealed pressure ulcers. R2's Care Plan dated 5/25/2025 documents R2 has potential for pressure ulcer development related to decline in medical, physical, mental status. incontinence. assist with transfers and turning and repositioning. Interventions include: R2 requires the bed as flat as possible to reduce shear. R2 prefers to be repositioned with 2 people, lifter. R2 requires pressure relieving device on bed/chair. R2's Braden scale for pressure ulcer development dated 5/12/2025 documents R2 is at moderate risk for pressure ulcer development. R2's progress notes dated 6/5/2025 at 8:53AM document Skin Issue: #001: New skin Issue. Location: Buttocks - generalized. Laterality / Orientation: Left. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Wound is new. Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 0.7 Width (cm): 0.7 Depth (cm): 0.1 Undermining: No. Tunneling: No. Skin Issues Note: order for triad paste put in place. Page 1 of 2 146040 146040 06/06/2025 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0686 R2's Clinical admission dated 5/27/2025 documents no skin issues. Level of Harm - Minimal harm or potential for actual harm R2's Skin Issues assessment dated [DATE] documents new issue, buttocks, pressure ulcer/injury, left. Stage 2, in house acquired. Stage by in house nursing, .7cm x .7cm x .1cm. Residents Affected - Few On 6/5/2025 at 8:30AM R2 stated, I got a pressure ulcer, and they haven't done anything. I have had a pressure ulcer before. I did have a cushion for my chair, but I don't know what happened to it. I like to be up in my chair all day. I like to smoke. On 6/5/2025 at 1:30PM R2 up in wheelchair in smoking area. R2 did not have a cushion or pressure relieving device in chair or on bed. On 6/5/2025 at 1:40PM V2 stated R2 was much more independent when she first came in. She wants to be up most of the day. We encourage her to lay back down in the afternoon or use a pressure relieving cushion. On 6/5/2025 at 1:40PM V3 stated, We encourage R2 to try one of the recliners to sit up in to relieve the pressure and reposition. She may have a cushion. Facility's pressure ulcer policy updated 6/2/2025 states: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven (7) days by licensed nurse and documented in the resident's clinical record. 146040 Page 2 of 2