Inspection·September 11, 2024

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 treatment orders for a resident with a stage 3 pressure injury. This applies to 1 of 2 residents (R5) reviewed for pressure injury in the sample of 12. Residents Affected - Few The findings include: R5's face sheet shows she was admitted to the facility on [DATE] with diagnoses including septic shock and a stage 3 pressure injury to her left heel and sacrum. Hospital discharge records for R5 show prior to admission to the facility she was in a local community hospital with a diagnosis of septic shock due to a left heel ulcer which had been debrided and antibiotic therapy provided while she was at the hospital. An initial nursing admission assessment for R5 dated 8/21/24 and not signed, shows she has a left heel ulcer measuring 1.6 centimeters (cm.) x 1.8 cm. The same assessment shows she has 3 open areas to her sacrum/coccyx and right and left buttocks measuring: 2.0 x1.0 cm. and 1.5 cm x 2.0 cm. and 1.0 cm. x 1.0 cm. R5's current Physician Order Summary (POS) and Treatment Administration Record (TAR) from 8/1/24-8/31/24 shows no active treatment orders for her coccyx and sacrum until 8/26/24, which was to initiate Medi-honey and Xero foam every other day and apply zinc ointment to her buttocks two times a day. There were no orders for her left heel ulcer until 8/26/24 when an order was entered to clean left ulcer with normal saline and apply iodoform, (sp.) xeroform and foam dressing daily. On 9/10/24 at 09:46 AM, V9 (Wound Nurse) said she initially saw R5 when she was admitted on [DATE] and assessed the wounds. R5 did not see the facility wound care physician until 8/29/24 because he was out of town. V9 said she thought there were orders prior to 8/26/24 for her sacral/buttocks and heel but verified with this surveyor by review of the POS and TAR that no orders were obtained until 8/26/24. V9 said R5 currently still has the pressure area to her heel but it has improved a lot. On 9/10/24 at 11:02 AM, V2 (DON) said she had reviewed R5's discharge orders from the hospital and she did not see any treatment orders for R5's pressure injuries. V2 said no treatment orders were obtained until 8/26/24 when V9 caught this and called the facility wound physician for orders. On 9/10/24 at 11:45 AM, V7 (Wound Care Physician) said he is treating R5 at the facility and she currently has only a pressure injury to her left heel. V7 said he was messaged or called on 8/26/24 for treatment orders for R5's pressure to her heel and coccyx. V7 said 5 days is not acceptable to wait to begin treatment to her heel wound because it could have deteriorated in that time. V7 said the (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 10 Event ID: 146069 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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)