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. (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 3 Event ID: 145456 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 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue Carlinville, IL 62626 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)