Inspection·June 22, 2022

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** 2. On 6/22/22 at 11:38 AM, V10 Registered Nurse changed the dressing to R4's pressure ulcer. R4 had a one centimeter round pressure ulcer the coccyx. Residents Affected - Few R4's Physician order dated 5/27/22 documents a treatment order to the coccyx. This order states to cleanse area, apply collagen wound dressing to the wound bed, and cover with an adhesive foam dressing every day. R4's electronic medical record did not contain an assessment of this wound until 6/21/22. R4's skin tracking form dated 6/21/22 documents R4 has stage 2 pressure ulcer that measures one centimeter by one centimeter on the coccyx. On 6/22/22 at 10:25 AM, V2 Director of Nursing stated there was not an initial assessment completed when R4's wound was identified on 5/27/22. V2 stated the wound was not assessed until 6/21/22. V2 stated wound assessments are supposed to be completed weekly. Based on observation, interview, and record review the facility failed to prevent the formation of a Stage II Pressure Ulcer caused by equipment, failed to assess a facility acquired Pressure Area and failed to prevent cross contamination during Pressure Ulcer dressing change for two (R16, R4) out of three residents reviewed for pressure ulcers in a sample list of 20 residents. Findings include: The facility policy titled 'Non Sterile Dressing Change' revised 8/16/18, documents the following: The wound is cleaned and protected with a dressing without contaminating the wound area, without causing trauma to the wound, and without causing the patient to experience pain or discomfort. 1. R16's undated Face Sheet documents an admission date of 5/17/22 and medical diagnoses of Chronic Kidney Disease Stage 3, Abnormal Finding of Lung Fields, Pneumonia, Open Wound of Right Lower Leg, Open Wound of Left Lower leg and Open Wound of Unspecified Buttock. R16's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status score of 15 out of 15 possible points indicating R16 is cognitively intact. This same MDS documents R16 as requiring extensive assistance of one person for bed mobility, dressing and personal hygiene and extensive assistance of two people for toileting and transfers. R16's Physician Order Sheet (POS) dated June 1-30, 2022 documents a physician order dated 6/16/22 to cleanse Left Shin with wound cleanser, apply absorbent pad and wrap with gauze daily. This same POS documents a physician order dated 6/20/22 to cleanse Coccyx with wound cleanser, apply Triple Antibiotic Ointment and cover with foam dressing daily. This same POS does not document a physician order for R16's Right Shin blister noted on 6/16/22. R16's Treatment Administration Record (TAR) dated June 1-30, 2022 documents treatment order dated 6/17/22 to cleanse Left shin with wound cleanser, apply absorbent pad and wrap with gauze daily. This dressing change to Left Shin was not signed off on 6/17/22, 6/18/22 nor 6/19/22. This same POS documents a physician order dated 6/20/22 to cleanse Coccyx with wound cleanser, apply Triple Antibiotic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 2 of 4 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 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Ointment and cover with foam dressing daily. This same TAR does not document a treatment order for R16's Right Shin blister noted on 6/16/22. R16's Nurse Progress Note dated 6/16/22 at 12:59 PM documents (R16) noted to have blisters to bilateral shins. Likely from rubbing against stand aid. Residents Affected - Few R16's Electronic Medical Record (EMR) does not document wound assessments for (R16) Left Shin Pressure Ulcer, Right Shin Pressure Ulcer and Coccyx Pressure Ulcer. On 6/21/22 at 1:35 PM V11 Registered Nurse (RN) completed (R16) dressing change to Left Shin and Coccyx pressure ulcers. V11 RN placed dressing supplies including absorbent pad, foam dressing and scissors on bedside table without cleaning table or providing clean field. R16's Left Shin dressing was not dated or initialed and was heavily saturated with yellow liquid over entire absorbent gauze and spilling over onto gauze wrap. R16's Coccyx dressing was not dated or initialed and was moderately saturated with yellow/pink drainage over 75% of foam dressing. V11 used scissors to cut dressing off of R16 lower Left Shin, placed contaminated scissors on fitted sheet of R16 bed and then used same contaminated scissors to cut dressing to place over R16's lower Left Shin pressure ulcer. On 6/21/22 at 2:30 PM V11 RN stated, V11 noted (R16) bilateral shin pressure ulcers on 6/16/22. V11 stated (R16) had been using stand aid and that is what caused the pressure ulcers to (R16's) bilateral shins. They started out as blisters and now they have opened and gotten bigger. I should have measured them then but must have got busy and did not get it done. (R16's) Coccyx pressure ulcer was caused because (R16) used to sit in (R16's) recliner and would scoot down in the chair all the time. (R16) was constantly scooting herself in that recliner. (R16) used to sleep in the recliner too so I am sure that was not good for (R16) skin on bottom. V11 stated should have provided clean field and disinfected scissors between using them on a soiled dressing and then using them to cut clean supplies. 6/22/22 at 12:10 PM V2 Director of Nurses (DON) stated, (R16) used the stand aid up until 6/16/22. That is the day the nurse (V11) noticed that the stand aid had caused pressure sores to (R16's) lower shins on both sides. The padding on the stand aid rubbed against (R16's) shins causing the wounds. (R16's) wounds on bilateral shins would be considered Stage II pressure ulcers. (R16) does not have any documentation of (R16)'s facility acquired pressure areas on coccyx and bilateral shins being unavoidable. There was never a physician order to treat (R16's) Right Shin pressure ulcer. (R16) did not see the Wound Physician. (R16) Hospice Nurse Practitioner was notified of these wounds but no order was ever entered for (R16) Right Shin pressure ulcer. The wounds to (R16's) bilateral shins and coccyx were never measured so we (facility) do not know if the wounds have worsened. The nurses should be measuring the wounds and also assessing for odor, redness, signs of infection, drainage and look of wound to determine if wound is improving or deteriorating. Since this was not done, I (V2) have no way of knowing if (R16's) wounds improved or deteriorated. Cross contaminating a wound could cause an infection. That gives access for bacteria to get into the wound and could make the resident very sick. (V11) should have created a clean field prior to placing any supplies on the bedside table. Anytime a nurse applies a dressing, it is to be dated and initialed. We (facility) have no way of knowing how long the dressings were on (R16) due to them not being dated and initialed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 3 of 4 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 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store and label premade salads and gelatin in a manner to prevent contamination. This failure had the potential to affect all 18 residents residing in the facility. Findings include: On 6/21/22 at 9:35 AM, bowls of individual premade salads which contained lettuce and cheese and two pans of setting gelatin where stored in the coolers in the kitchen. These salads and pans of gelatin where not covered or dated. V6 Dietary Manager who was present stated the salads and gelatin should be covered and dated. V6 stated both the salad and gelatin would be served at the lunch meal. The facility's census and condition report dated 6/21/22 signed by V2 Director of Nursing documents there are 18 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 4 of 4