Health inspection·January 21, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 assess and identify open areas to the right and left buttocks, this failure resulted in R1's open areas becoming full thickness for 1 of 3 residents (R1) reviewed for pressure injury in the sample of 3. Residents Affected - Few The finding include: R1's Physician Order Sheet printed on 1/21/25 show R1 was admitted to the facility on [DATE] with diagnoses of pancreatic cancer, Type 2 diabetes, and chronic kidney disease. R1's facility assessment dated [DATE] show R1 has no cognitive impairment. (BIMS-15) R1's Braden scale (predicting of risk of pressure injury) dated 12/20/24 show R1 is at risk to develop a pressure injury. R1's skin admission assessment dated [DATE] show R1 had redness to his bottom but no open areas. On 1/21/25 at 9:10 AM, R1 said he was having so much pain in my bottom, I was complaining about it, until they saw that I had an open sore while they were cleaning and changing me. R1 said he did not have any wounds on his bottom when he first came at the facility (12/13/24.) On 1/21/25 at 10AM, V9 (Wound Nurse) provided wound care to R1. V9 removed the soiled dressing from the right and left buttocks. There were open areas to R1's right and left buttocks. V9 said she was informed of R1's open areas on 1/9/25. V9 said she took pictures and sent them to V10 (Wound Physician). V10 was then at the facility last 1/15/25 and assessed R1's wounds. R1 had no other skin assessments in R1's medical record after R1's initial skin assessment (12/14/24). R1 had no skin assessments the week of: 12/16/24, 12/23/24 and 12/30/24 (no skin assessments for 3 weeks) prior to a progress note on 1/9/25 when the open wound to right and left buttocks were discovered. Skin opening noted to right and left buttocks . Area cleanse with normal saline . R1's Wound assessment dated [DATE] by V10 documents, initial wound assessments on the right buttocks-full thickness 5.0 centimeters (cm) x 3.5 cm x 0.1 cm. Initial assessments left buttocks-full thickness 3.5 cm x 1.5 cm x 0.1 cm treatment with date of order (1/15/25) to right and left buttocks-mupirocine 2% with santyl and lidocaine jelly with calcium alginate cover with foam dressing. On 1/21/25 at 1:30 PM, V2 (Director of Nursing/DON) said skin assessments should be done upon admission and then weekly. V2 said the skin assessments on 1/9/25 was when the open areas on right and Page 1 of 3 146136 146136 01/21/2025 Radford Green 960 Audubon Way Lincolnshire, IL 60069

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left buttocks were discovered. V2 confirmed R1 no skin assessments were completed the week of: 12/16/24, 12/23/24 and 12/30/24. R1's care plan with a range date of 12/13/24 show R1 is at risk for impaired skin integrity related to weakness and occasional bowel and bladder incontinence with intervention to check skin for redness. Skin tears swelling or pressure areas. 146136 Page 2 of 3 146136 01/21/2025 Radford Green 960 Audubon Way Lincolnshire, IL 60069

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's sink faucet was in working order for 1 of 3 residents (R1) reviewed for environmental services in the sample of 3. The findings include: R1's facility assessment dated [DATE] show R1 has no cognitive impairment-(BIMS of 15) On 1/21/25 at 9:10 AM, R1 was in bed alert and pleasant. R1 said it took the staff, days before they were able to fix his sink faucet. There was no water coming out since the faucet was broken. R1 said there was no water to brush his teeth. Staff had to get the water from outside. A document entitled Maintenance work order dated 1/10/25 (Friday)-Faucet in room XXX-Faucet is broken in the sink in room XXX. The same document show, Priority .same day. On 1/21/25 at 12:44 PM, V4 (Registered Nurse Weekend Supervisor) said last Saturday 1/11/25 it was reported to her that the faucet in R1's room was still broken. R1's wife was also in the room at that time and was asking when it will be fixed. V4 said she notified V3 (Assistant Director of Nursing/ADON). V4 also said she provided buckets of water to R1 to be used during care. On 1/21/25 at 12:52 PM, V3 (ADON) said when she was informed regarding R1's faucet sink not working, it was facilitated for the Maintenance of the Assisted Living to come over and fix R1's sink faucet. On 1/21/25 at 12:11 PM, V6 said he was the Maintenance at the Assisted Living. V6 said he was requested to go the Long Term to fix a faucet. He got the call on Saturday 1/11/25. V6 said he went to the Long-Term unit the next day (1/12/25 Sunday afternoon). R1 and his wife were in the room. The wife said it has not been working for days now. V6 said the faucet was broken. I explained that I cannot fix the faucet at that time. It will need a whole replacement. On 1/21/25 at 10 AM, V5 (Maintenance) said he fixed the faucet on 1/13/25 (Monday) first thing in the morning. V5 said he replaced the faucet, and it was now working fine. V5 said if V6 would have only called that weekend, I would have given him direction where to get the parts so it would have been taken cared of same day. The facility policy entitled Maintenance Service dated 12/2009 states, 1. The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner. 146136 Page 3 of 3