Inspection·January 21, 2026

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 document changes in skin condition, failed to ensure a physician assessed a new wound. The facility also failed to develop and implement care plan interventions for a resident who was admitted with pressure wounds to both heels, was identified with risk factors for further pressure wound development, and who developed sacral pressure wounds. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 5. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, moderate protein calorie malnutrition, gout, bilateral heel wounds, low back pain, and dysphagia. R1 was discharged from the facility on January 1, 2026. R1's MDS (Minimum Data Set) dated December 11, 2025, showed R1 was severely cognitively impaired and dependent on staff assistance with all ADLs (Activities of Daily Living) including eating, bed mobility, toileting, dressing, bathing and transfer. R1's progress note, dated December 30, 2025, at 11:06 PM, showed R1's physician ordered R1 transferred to the hospital due to abnormal lab results. R1 was transferred to the local hospital on December 31, 2025, at 00:46 AM and was admitted to the hospital with a diagnosis of pneumonia. R1's tissue tolerance assessment dated [DATE], completed by V7 (Registered Nurse/RN) showed R1 needed repositioning more often than every 2 hours. R1's skin condition assessment dated [DATE], showed R1 had a pressure ulcer on his right heel. The assessment also showed, in the interventions section, R1 had pressure relief device in chair, turning and repositioning program, nutrition and hydration interventions and dressing changes all identified as ongoing interventions in the past 7 days. The skin condition assessment showed to initiate care plan. R1's care plan initiated on December 8, 2025, showed there was no care plan in place to address pressure ulcer prevention such as need for turning and repositioning program, due to R1's immobility, incontinence or behavior of being aggressive when touched. The care plan did not include devices staff could use such as a positioning wedge or pillows, to encourage turning and repositioning or a schedule for repositioning for staff to follow. There was no care plan in place to address off loading of resident's heels while in bed. The nutrition care plan did not include strategies for feeding R1 or include what staff should do if R1 refused to eat. R1's daily shower skin check sheets were provided by the facility. R1 had skin check sheets dated December 5, 12, 16, 19, and 23, 2025. On the skin check sheets dated December 5, the skin check indicated R1's skin was intact with the presence of a bruise but no location of where the bruise was. The skin check sheet dated December 16 indicated R1 skin was intact with presence of rash and bruise with no location of where the rash and the bruise were located. The skin check sheets dated December 12, 16 and 23 did not have any documentation including whether or not skin was intact regarding R1's skin. V2 (Director of Nursing) was unable to provide any follow up documentation or interventions that were provided regarding the skin concerns identified. R1's observation note dated December 23, 2025, at 11:51 PM, by V8 (RN) showed R1 developed pressure ulcers on both sides of his Residents Affected - Few (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: 146065 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 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 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)