Alden Estates Of Naperville

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement wound care interventions as ordered for a resident with pressure injuries.This applies to 1 of 3 residents (R1) reviewed for pressure injuries.The findings include:On 8/30/2025 at 11:30 AM, R1 was in bed on a regular mattress. V5 (Wound Care Nurse) and V6 (Wound Care Technician) said R1 had multiple wounds identified as present on admission on [DATE], including stage 2 pressure injuries to his right and left buttock areas. V5 said R1's wound care was being managed by the wound physician and R1 required daily dressing changes. V5 continued to say she was concerned because R1's wound showed signs of deterioration today, as evidenced by an increase in size measurement. V5 then assessed R1's pressure injuries, which were open with minor bleeding and had peri-wound irritation. V5 said R1's left buttock wound measured 3 centimeters (cm) x 2 cm x 0.1 cm and the right buttock wound measured 0.6 cm x 0.6 cm x 0.1 cm. V5 said she believed R1 was provided with an air loss mattress upon admission. V5 said R1 had a room change on 8/24/2025 and was unsure why R1 was not currently provided with his ordered specialized mattress. V5 said wound care management interventions should be followed as ordered to prevent skin and wound deterioration.On 8/30/2025 at 2 PM, V2 (Director of Nursing/DON) said wound care interventions should be implemented as ordered, including an air loss mattress.R1's initial wound physician consultation dated 8/18/2025, said R1's left buttock stage 2 pressure wound measured 0.7 cm x 0.7 cm x 0.1 cm, and right buttock stage 2 pressure wound measured 0.7 cm x 0.5 cm x 0.1 cm.

The consultation report included an order for low air loss mattress as part of R1's wound management plan.R1's wound physician consultation dated 8/25/2025, said R1's left buttock stage 2 pressure wound measured 0.5 cm x 0.5 cm x 0.1 cm, and right buttock stage 2 pressure wound measured 0.4 cm x 0.5 cm x 0.1 cm.R1's Order Summary Report dated 8/30/2025 showed an active order for Low air Loss Mattress initiated 8/16/2025.R1's care plan said R1 was at risk for further skin breakdown due to his multiple wounds.

The care plan had an intervention initiated on 8/25/2025 for pressure redistribution support (low air or alternation air) in bed.The facility's policy titled Prevention and Treatment of Pressure Injury and Other Skin Alterations dated 3/02/2021, said Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan.The facility's policy titled Management of Low Air Loss Mattress dated 03/2024, said Residents who have been assessed as in need of a low air loss mattress will have a mattress set up for their use.

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.

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