Health inspection·June 18, 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 interview and record review the facility failed to obtain timely treatment orders and complete physician ordered treatments for one (R1) of three residents reviewed with pressure ulcers in the sample of 10. Residents Affected - Few Findings include: R1's face sheet documents an admission date of 10/10/2024. Diagnosis include Congestive Heart Failure, Pneumonia, Urinary Tract Infection, Type 2 Diabetes. R1's Minimum Data Set, MDS, dated [DATE] documents R1 has no cognitive deficits. R1's MDS dated [DATE] documents R1 has 2 stage 2 unhealed pressure ulcers and is at risk for pressure ulcers. R1's care plan updated 1/23/2025 documents Potential for skin breakdown related to bowel incontinence, weakness, redness to peri area. 11/26/24 Stage 2 left buttock 3/5/25 Stage 2 right buttock; Interventions include reposition every 1-2 hours. Monitor for redness or discoloration to skin. Weekly skin checks. R1's Braden Scale for Predicting Pressure Sore Risk dated 10/31/2024 documents R1 is at high risk for pressure ulcer development. R1's shower sheets dated 6/5/2025, 6/9/2025, and 6/12/2025 all circled left heel as area of abnormality. No progress notes, treatments, or orders on corresponding dates noted. R1's weekly wound evaluation dated 6/10/2025 has no documentation of left heel. R1's weekly wound evaluation dated 6/17/2025 documents left heel stage 3. Comments stated resident does not sleep in bed, he sleeps in recliner. treatment order 6/14. May refer to wound company. Follow up in place. Medical Doctor to be consulted with Nurse Practitioner from wound company. R1's order sheet dated 6/14/2025 documents Left Heel, cleanse with normal saline or wound cleaner. Apply calcium alginate to wound and cover with dry dressing. One time a day. R1's treatment administration records, TARS, dated June 2025 document Left Heel, cleanse with normal saline or wound cleaner. Apply calcium alginate to wound and cover with dry dressing. one time a day -Order Date 6/14/2025 5:00AM. Treatments completed on 6/16/2025, 6/17/2025, and 6/18/2025. No treatment completed on 6/14/2025 and 6/15/2025. Page 1 of 2 146043 146043 06/18/2025 Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263

F 0686 R1's Skilled Nursing assessment dated [DATE] has no documentation of left heel pressure ulcer. Level of Harm - Minimal harm or potential for actual harm R1's progress notes dated 6/17/2025 at 12:03PM documents Specialized Wound Management follow up wound evaluation. Wound :1 Status: Subsequent Improving. Location: Coccyx. Primary Etiology: Pressure injury/ulcer. Severity Stage 2. No documentation of left heel pressure ulcer. Residents Affected - Few R1's progress notes dated 6/17/2025 at 5:36PM document R1 was seen in the facility by Nurse Practitioner for wound company today, 6/17/25. Wound to coccyx is improving. Treatment to stay the same with no new orders. No documentation about left heel. On 6/17/2025 at 10:30AM R1 up in wheelchair with shoes on. On 6/17/2025 at 3:00PM R1 up in wheelchair with shoes on. On 6/17/2025 at 11:00AM V2, Director of Nursing, DON, stated TARS should've documented that treatment was completed on R1's heel on 6/14/2025 and 6/15/2025. V2, DON, stated It takes a little time to get the order for wound company to see but they should've documented that a treatment was done on 6/14/ 25 and 6/15/25. On 6/17/2025 at 3:20PM V3, Infection Control Specialist, ICPC/Wound nurse, stated I rounded with the wound company today. All wounds were changed. I was not in the room when the wound Nurse Practitioner treated R1's wounds so I do not know if R1's heel was looked at. On 6/18/2025 at 12:55PM V3, ICPC/Wound nurse stated I saw R1's heel before it was open. His heel was darkened and thin. We were putting skin prep on it. It was not open before 6/14/25. Facility policy with a revision date of 4/2013 states The nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores, for example, immobility, recent weight loss, and a history of pressure ulcers. The physician will help identify factors contributing or predisposing residents to skin breakdown; for example medical comorbidities such as diabetes or congestive heart failure, overall medical instability cancer or sepsis causing a catabolic state and macerated or fragile skin. 146043 Page 2 of 2