Inspection·November 17, 2022

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to implement interventions in preventing the development of a pressure ulcer in relation to repositioning and skin monitoring for one (R12) of one resident reviewed for pressure ulcers in the sample of 26. This deficiency resulted in R12's stage III pressure ulcer in the coccyx area worsen to stage IV pressure ulcer with ongoing infection requiring antibiotic therapy. Residents Affected - Few Findings include: R12 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including but not limited to Hypertensive Heart Disease with Heart Failure; Paroxysmal Atrial Fibrillation; Unspecified Osteoarthritis, Unspecified Site; Dysphasia, Oropharyngeal Phase; and Unsteadiness on Feet. According to MDS (Minimum Data Set) dated 10/25/2022 under Section C, R12 has a BIMS (Brief Interview of Mental Status) score of 12 indicating a moderately impairment of cognitive functioning. According to MDS (Minimum Data Set) dated 10/25/2022 under Section G, R12 requires extensive assist of two + person physical assist in Bed Mobily including turning side to side. According to MDS (Minimum Data Set) dated 10/25/2022 under Section M, R12 is at risk for developing pressure ulcers/injuries and has one stage four pressure ulcer that was not present upon admission. On 11/14/22 at 11:04 AM Surveyor observed R12 lying in bed in supine position. R12 utilizing low air loss mattress, set up to static mode. Upon interview R12 stated, I have a wound on my behind. Per record review, progress note completed by V14 (Registered Nurse) dated 10/15/2022 reads in part, Stage III wound in coccyx area. 2cm x 3cm x 05cm. Cleaned and secured. Will endorse to next shift. No previous documentation pertaining R12's wound present. On 11/15/22 at 9:47 AM Surveyor observed R12's wound dressing change. V8 (Registered Nurse, corporate/mobile MDS) and V9 ((Licensed Practical Nurse) performed dressing change. V8 (RN) stated, Wound clinic has been following R2's wound. R12 has a stage IV pressure ulcer on coccyx. It is also infected, which R12 gets antibiotics for. I'm just helping lately with wound care, since the Assistant Director of Nursing has been gone; it used to be the ADON who took care of wounds at the facility. ADON been gone since the beginning of October of this year. V9 (LPN) stated, ADON was a wound care nurse from Monday to Friday and staff nurses would do wound care on the weekends. ADON did rounds with wound doctor as well. Wound dressing change observed, wound measurements 4cmx5cmx2.5cm appearing as tennis ball size with additional underlining and tunneling. Wound dressing changed per order. Plan of Service dated 10/21/2022 reads in part, Santyl ointment coccyx wound cleanse with normal (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 3 Event ID: 146180 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 146180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Nazarethville Place 300 North River Road Des Plaines, IL 60016 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)