Health inspection·January 30, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide timely assessment and treatment for a wound for 1 of 5 residents (R2) reviewed for quality of care in the sample of 7. Residents Affected - Few Findings include: On 1/29/2024 at 12:40PM V13, Certified Nursing Assistant (CNA) removed a sock from R2's feet. R2's second toe of Right foot, was observed as having the toenail off and dried blood. No dressing in place as verified by CNAs. R2's Physician Orders (PO) dated 1/15/2025 documents refer to wound care for consult as needed. R2's PO dated 1/17/2025 documents Right (R) second toe as needed cleanse to R second toe with wound cleanse, apply skin prep and cover with dry dressing change 3 times a week and as need (prn). R2's PO dated 1/15/2025 with documented start date 1/19/2025, documents R second toe every day shift every Tuesday, Thursday and Sunday; cleanse area to R second toe with wound cleanser, apply skin prep and cover with dry dressing change 3 times a week and prn. R2's skin and wound note dated 1/16/2025 by wound care documents right second toe full thickness abrasion. The skin and wound note documents treatment recommendations as cleanse with wound cleanser, apply antibiotic ointment to base of wound and secure with bordered gauze. R2'a Treatment Administration Record (TAR) dated 1/1/2025-1/31/2025 fails to document this treatment. R2's Treatment Administration Record (TAR) dated 1/1/2025-1/31/2025 fails to document any type of treatment orders for R2 second toe on right foot until 1/17/2025. On 1/29/2025 at 10:55AM V14, facility transport stated she provided transport for R2 from hospital in [NAME] to the facility on 1/15/2025. V14 stated when pushing R2 into the facility R2's foot hit the plate at the bottom of the door. V14 stated it was bleeding and she notified the nurse. On at 1/29/2025 at 1:15PM V18, wound nurse stated current treatment of R2's toe is to be cleansed, skin prep, and dry dressing. On 1/29/2025 at 1:33PM V18 wound nurse stated she would expect dressings to be done as ordered and residents The facility policy Physician orders dated, revised 4/21/2023, documents the facility will obtain, process and implement physician orders. Page 1 of 3 145456 145456 01/30/2025 Lakeside Health & Rehab Center 1200 University Avenue Carlinville, IL 62626

F 0684 Level of Harm - Minimal harm or potential for actual harm The facility policy clean dressing change dated 7/1/2023 documents to verify there is a physician's order (PO) for the procedure. The policy documents to apply the ordered dressing and secure with tape or bordered dressing per order. Residents Affected - Few 145456 Page 2 of 3 145456 01/30/2025 Lakeside Health & Rehab Center 1200 University Avenue Carlinville, IL 62626

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent injury to R2's right second toe during transport to the facility from the hospital. This failure resulted in R2's right toe striking the plate at the bottom of door, causing a wound to the second toe of right foot and toenail being removed. Findings include: On 1/29/2025 at 12:40PM V13, Certified Nursing Assistant (CNA) removed socks from R2's feet. R2's second toe of right foot, toenail is off and area dried blood. No dressing in place as verified by V13. On 1/29/2025 at 10:55AM V14, facility transport stated she provided transport for R2 from hospital in (town name) to the facility on 1/15/2025. V14 stated when pushing R2 into the facility R2's foot hit the plate at the bottom of the door. V14 stated it was bleeding and she notified the nurse. On 1/29/2025 at 12:50PM V8 Licensed Practical Nurse (LPN) stated she was on duty when R2 arrived at the facility on 1/15/2025. V8 stated R2's toenail was off and bleeding. V8, LPN stated they cleansed wound and applied dressing. R2's face sheet dated 1/29/2025 documents in part a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R2's Minimum Data Set (MDS) dated [DATE] documents unable to interview for Cognition. R2's MDS documents R2 is dependent on staff locomotion with wheelchair. R2's Physician Orders (PO) dated 1/15/2025 documents refer to wound care for consult as needed. R2's skin and wound note dated 1/16/2025 by wound care documents right second toe full thickness abrasion. R2's Care Plan dated 1/18/2025 documents R2 has an actual impairment to skin integrity of the right second toe related to abrasion. R2's care plan documents the following interventions dated 1/18/2025; use caution during transfers and bed mobility to prevent striking arms, legs and hands against any hard surfaces, monitor/document location, size and treatment of skin injury at least weekly. Report abnormalities, failure to heal, signs and symptoms of infection, maceration to physician. On 1/29/2025 at 1:33PM V18 wound nurse stated she would expect residents to be provided safe assistance during transport from the hospital by the facility transport staff. On 1/29/2025 at 3:00PM V19, Regional nurse stated the facility does not have a policy on facility transport. 145456 Page 3 of 3