Inspection·December 3, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow physician's orders for a resident with a rash for 1 of 3 residents (R3) reviewed for pharmacy services in a sample of 4. Findings include: R3's Face Sheet documents he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, aphasia, Parkinson's disease and dementia, no skin rash diagnosis was documented. R3's Skin Inspection assessment dated [DATE] rash continues to BUE (bilateral upper extremities), BLE (bilateral lower extremities) and torso, 11/9/2024 current skin concerns: back/upper arm clearing rash, tx (treatment) in place, 11/16/2024 current skin concerns: rash to torso, arms and thighs. R3's Nurse's Notes, dated 11/18/2024, documents, Resident seen by MD this afternoon new orders to D/C (discontinue) Clopidogrel and start Triamcinolone and Clotrimazole topically BID (twice a day.) Follow up in 1-2 weeks. R3's Physician's Order Sheet (POS), dated 11/18/2024 through 11/27/2024 documents no physician's order for Triamcinolone or Clotrimazole BID. R3's Treatment Administrator Record (TAR), dated 11/18/2024 through 11/27/2024 documents no Triamcinolone or Clotrimazole was administered. On 11/27/2024 at 11:30 AM V2, Director of Nurses (DON) stated on 11/18/2024 the nurse notified the physician that they needed clarification on the dosage for the Triamcinolone and Clotrimazole and the communication fell through, so the medications were not ordered and therefore the nursing staff have not administered the medications per physician's orders. V2 stated she got the medication dosage clarified today and the medications will be delivered to the facility within the next 8 hours. V2 expected all physician's orders to be followed and to follow up with clarification of medications within the same shift. On 11/27/24, at 10:07 AM V8, Certified Nurse Aide (CNA) was showering R3 and he had a red raised rash on back and abdomen and legs all over. V8 stated they use (brand named) soap, and she puts regular lotion on his skin but nothing else, physician prescribed lotion is applied by the nurse. The Facility's Physician Orders Policy, initiated 7/1/2023 documents the purpose of this policy is to establish uniform guidelines in the receiving, recording, and processing of physician orders. (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: 145286 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 145286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Staunton Health and Rehab Ctr 215 West Pennsylvania Avenue Staunton, IL 62088 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)