Health inspection·April 10, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to carry out treatment orders for an antibiotic ointment and failed to promptly notify a physician after the deterioration of a non pressure wound. These failures contributed to a delay in R1 missing 9 days of an antibiotic ointment and a delay in a physician assessing R1's left heel arterial ulcer. This applies to 1 of 3 residents reviewed for quality of care in the sample of 5. Residents Affected - Few The findings include: R1's Face Sheet shows she was admitted to the facility on [DATE] and has diagnoses including: Type 2 diabetes with foot ulcer, displaced fracture of the 5th metatarsal bone of the left foot, hypertensive chronic kidney disease with end stage renal disease, renal dialysis, chronic pain, and anxiety disorder. R1's Care Plan shows she has a diabetic ulcer to her left foot and interventions include monitoring the area and notifying the physician of any changes including signs of infection, worsening of the wound based on size, appearance or odors and drainage. A Orders and Recommendations form signed by V5 ( Podiatrist and foot specialist) on 11/6/24 shows an order for R1 to apply Triple Antibiotic Ointment and a dry sterile dressing to her left heel ulcer daily. R1's 11/1/24-11/30/24 Treatment Administration Record (TAR) shows the Antibiotic Ointment was not administered for the first time until 11/15/24. (9 days after the treatment order was written) R1's Physician Order Summary (POS) shows the order was not entered into R1's Electronic Medical Record (EMR) until 11/14/24. R1's 11/8/24 Wound Assessment Report completed by V8 (Licensed Practical Nurse/LPN and covering wound nurse) shows R1 has a full thickness vascular diabetic ulcer measuring 1.50 centimeters (cm.) x 0.50 cm. there is no documented drainage to the wound. The wound bed is described as necrotic hard, firm. R1's 11/12, 11/19 and 11/25 wound assessments show the same descriptions to her wound bed with no changes. On 12/2/24 R1's wound assessment shows an increase in size to 2.00 cm. x 1.00 cm. On 12/10/24 R1's wound assessment shows the area measuring 1.50 cm. x 1.30 cm. with the overall surface size of 1.95 cm. The picture (in black and white) of the wound on the assessment form gives the Page 1 of 3 145295 145295 04/10/2025 Goldwater Care Marseilles 578 West Commercial Street Marseilles, IL 61341

F 0684 appearance the wound is worsening and appears deeper. Level of Harm - Actual harm On 12/16/24 the wound assessment shows it is 2.00 cm. x 1.30 cm. with a surface area of 2.60 cm and the wound photo shows what appears to be slough beginning in the wound bed. Residents Affected - Few On 12/30/24 the wound assessment shows there is now a moderate amount of serous drainage to the wound bed. On 1/13/25 the wound is now 3.0 cm x 3.0 cm and a total wound surface area of 9.0 cm. R1's 12/1-12/31/24 TAR shows a treatment order change for the wound that was given on 12/18/24 by V3 (Wound Care Physician). R1's Physician Progress notes show V14 (former facility Nurse Practitioner) documented R1's wound on 12/3/24 and described it as dry cracked skin to left heel and documents not healing. R1's 12/26/24 physician note refers to R1's wound and states she was provided with a diabetic shoe. Neither note shows that V14 saw R1 or that she was informed of the wound deterioration. R1's Progress note completed by V15 (R1's Physician and Medical Director) on 12/28/24 states, no issue is noted per nursing staff and does not mention R1's wound. The first wound care assessment documented by V3 was not until 1/14/25 and the wound was then described as 3 cm x 3 cm x 0.1 cm and has heavy serous drainage and 90% necrotic tissue and 10% slough. On 4/8/25 at 12:17 PM, V3 said he was not able to recall when he first saw R1 but said he should be contacted to see a resident if the wound shows heavy drainage, signs it is not healing, increased size or signs of necrosis. V3 said R1 would allow him to assess her wound and do treatments like debridement for the wound. V3 described her wound as a full thickness with soft necrosis. V3 reviewed his assessments with the survey and agreed his first assessment for R1's wound was on 1/14/25. On 4/9/25 at 9:25 AM, V8 said she was aware that the order for the Triple Antibiotic Ointment was not carried out on time. V8 said the nurse who got the order did not enter it into the EMR so it was missed until she caught it and added it to the treatments. V8 said in her opinion 12/10/24 was the start of the deterioration of R1's wound. V8 said she did not call to report this to anyone because R1 was supposed to have a podiatry appointment on 12/11/24 but R1 canceled that appointment and canceled again on 12/18/24. V8 said she called V3 to get an order to change the treatment for R1's wound care on 12/18/24. V8 said she would call a physician if a wound increases in size, is not healing, has heavy drainage or has signs of an infection. V8 did not call V5 or V14 to report the wound condition change. V8 said V3 first saw R1 on 1/14/25. V8 said initially R1 wanted to be seen by her own outside provider (V5) but there is nothing documented in R1 EMR's showing she refused the services or to be seen by V3. V8 also said R1 had been in the hospital from 12/22-12/25/24 and again from 1/6/25-1/12/25 for non related medical issues. On 4/9/25 at 11:17 AM, V5 said he did see R1 on 11/6/24 and gave orders for her to start the Triple Antibiotic Ointment daily to her wound. V5 said no one from the facility called to report that this was not started (until 9 days later) and this was a concern because this medicated ointment is an antibiotic to prevent infection, and by R1 not receiving it bacteria could build up in her wound bed. V5 also said no one contacted him to report the worsening wound. 145295 Page 2 of 3 145295 04/10/2025 Goldwater Care Marseilles 578 West Commercial Street Marseilles, IL 61341

F 0684 Level of Harm - Actual harm Residents Affected - Few The facility provided Skin Condition Assessment & Monitoring- Pressure and Non-Pressure last revised 6/8/18 shows when there is changes to a wound physicians should be notified and that should be documented in the residents clinical record. Changes described that would require notification include onset of drainage, odor, cellulitis, increased pain, increase in wound measurements and onset of new ulcers. The facility provided Entering and Processing orders policy last revised on 1/31/18 shows after a physician visit the nurse should check for orders and the order will be completed and entered into the EMR. 145295 Page 3 of 3