Health inspection·February 24, 2025

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 observation, interview and record review the facility failed to ensure staff followed physician orders for pressure injuries. This applies to 2 of 4 residents reviewed for pressure injures in the sample of 4. Residents Affected - Few The findings include: 1. R2's electronic medical records (EMR) lists his diagnoses to include: displaced intertrochanteric fracture of right femur, muscle weakness and need for assistance with personal care. On February 20, 2025 at 12:05 PM, V3 wound care nurse (WCN) was changing R2's sacral dressing. R2's sacral dressing was dated February 16, 2025 and there was stool on the bottom portion of the dressing. Once the dressing was removed there was an open wound on both buttocks. The right side was approximately a quarter size open area. The left side was an elongated quarter size open area. Both wound areas were red and pink. The right side had some purplish tissue inside the wound. R2 stated, he fell and broke his hip which resulted in him laying in the bed too much. He stated, the dressings have only been changed 3 or 4 times. Some one changed them a few days ago otherwise no one has looked at his wound. V3 WCN verified the dressing was dated February 16, 2025. R2's wound assessment details report dated for February 20, 2025 shows, Wound: left ischial tuberosity, type: pressure, clinical stage: unstageable, size: 2.00 cm (centimeters) X 5.00 cm X 0.20 cm (length x width x depth). Another assessment dated [DATE] shows, Wound: right ischial tuberosity, type: pressure, clinical stage: unstageable, size: 4.00 cm X 3.00 cm X 0.20 cm. R2's treatment administration record (TAR) for the month of February 2025 shows, Left ischium: cleanse with NS (normal saline), pat dry then apply oil emulsion to wound bed, cover with foam until resolved. Change every Monday, Wednesday and Friday The last time the wound was signed off as being completed was February 19, 2025 (Wednesday) (the dressing was dated February 16, 2024(Sunday)). There is no sign offs for February 7th, 10th, 14th or 17th, 2025. The same TAR for the right ischium shows, the same phyisican order as well as no sign offs on the same dates. The TAR also shows, the last time the right ischium was changed was on February 19, 2025 (Wednesday) (the dressing was dated February 16, 2025(Sunday)). On February 20, 2025 at 12:05 PM, V3 WCN stated, he is responsible for the dressing changes during the week (Monday-Friday). There is another nurse that helps on the weekends or if he is not there. If he is unable to get to dressing changes he does let the nurses know. The floor nurses are responsible if he is not able too. He was on vacation for the past two weeks and today (February 20, 2025) was his first day back. (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: 146195 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 146195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical McHenry 550 Ridgeview Drive McHenry, IL 60050 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)