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. Page 1 of 2 146195 146195 02/24/2025 Ignite Medical McHenry 550 Ridgeview Drive McHenry, IL 60050

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On February 20, 2025 at 1:10 PM, V6 Assistant Director of Nursing stated, V3 WCN does the treatments. He was on vacation for the past two weeks. Ultimately the nurses are responsible for the dressing changes. R2's Minimum Data Set, dated [DATE] , 2025 shows, he is cognitively intact. R2's care plan dated January 18, 2025 shows, Focus: R2 has an actual alteration in skin integrity r/t (related to) Pressure Injuries to Right Heel, Left Heel, as well as to Bilateral Ischium, a Skin Tear to Left Elbow, a Partial Thickness wound to Right Shin and a Surgical Incision to Right Hip all noted upon admission to facility. Interventions: Provide skin/wound treatments as ordered . 2. R1's EMR lists his diagnoses to include: chronic kidney disease, heart failure, diabetes mellitus type II, chronic obstructive pulmonary disease, morbid obesity, difficulty in walking and need for assistance with personal care. On February 20, 2025 at 9:45 AM, V7 hospital Registered Nurse (RN) stated, R1 was her patient at the hospital. He self reported that the dressing on his sacrum had not been changed in over a week. R1 was a good historian and alert and oriented x 3. R2's physician order details form dated February 10, 2025 shows, Wound #1 Right buttock is an acute unstageable pressure injury obscured full thickness skin and tissue loss pressure ulcer and has received a status of not healed . Plan: Wound Orders: Wound #1 right buttock: cleanse with normal saline and dakins 1/4 strength, protect periwound with barrier treatment, apply barrier cream/ointment, apply foam dressing and change daily . R1's TAR for February 2025 does not show the order the physician ordered on February 10, 2025. The TAR shows, Right ischium: cleanse with NS (normal saline), pat dry then apply zinc oxide until resolved. There is the same order for left ischium and sacrum as well. All three orders are for every shift (days and evenings). Every evening is signed off as completed however only four of the day shifts are signed out as completed. There is nothing on R1's TAR that shows he has a dressing to cover the wound or to be changed daily. R1's Minimum Data Set, dated [DATE] shows, he is cognitively intact. R1's care plan dated January 30, 2025 shows, Focus: R1 has an actual alteration in skin integrity r/t Pressure Injuries to sacrum, left and right ischia as well as Partial Thickness wounds to BLE (bilateral extremities). Interventions: Provide skin/wound treatments as ordered. On February 20, 2025 at 12:45 PM, V3 WCN confirmed that R1's orders were not entered as the wound care doctor had ordered them. He stated, the wound care doctor is new to the facility and he was on vacation for the past two weeks. The facility's skin policy and procedure dated March 2020 shows, .If the resident has, on admission, or develops pressure sore(s), he/she will receive necessary and appropriate treatment and services to promote healing, prevent infection and prevent further development of additional impaired skin integrity. The interdisciplinary team, including the physician will create a written plan for the treatment of impaired skin integrity which will be included in the resident's individualized plan of care. 146195 Page 2 of 2