Health inspection·November 25, 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 interview and record review, the facility failed to ensure a dermatologist referral was sent when residents were experiencing skin rashes as ordered by the physician for six of ten residents (R1, R7, R8, R9, R10) reviewed for quality of care in the sample of ten. The findings include: 1. R1's admission Record shows he was admitted to the facility on [DATE]. R1's Order Summary Report shows an order for a dermatologist referral due to ongoing rash not improving with treatment. This order was entered on October 30, 2025. The facility's List of Rash Data dated 2025 shows R1 acquired a rash to his torso starting on October 11, 2025. On November 25, 2025, at 10:08 AM, R1 said that he has a rash on both of his arms and other places on his body. R1 said he gets cream applied, but it makes the itching worse. R1 said the facility does not know where the rash came from. 2. R7's admission Record shows he was admitted to the facility on [DATE]. R7's Order Summary Report shows an order for a dermatologist referral due to ongoing rash entered on October 30, 2025. The facility's List of Rash Data dated 2025 shows R7 has been experiencing a rash to his arms and back off and on for three months. 3. R8's admission Record shows she was admitted to the facility on [DATE].R8's Order Summary Report shows an order to refer R8 to a dermatologist due to an ongoing rash was entered on October 30, 2025.The facility's List of Rash Data dated 2025 shows R8 has been experiencing a rash to her arms and chest since July 2025.4. R9's admission Record shows she was admitted to the facility on [DATE].R9's Order Summary Report shows an order to refer R9 to a dermatologist due to an ongoing rash was entered on October 30, 2025.The facility's List of Rash Data dated 2025 shows R9 began a rash to her right shoulder on October 16, 2025.5. R10's admission Record shows she was admitted to the facility on [DATE].R10's Order Summary Report shows an order to refer R10 to a dermatologist due to an ongoing rash was entered on October 30, 2025.On November 25, 2025 at 8:27 AM, V3 Wound Care Nurse said she started working at the facility in September 2025. V3 said there was a few residents that were experiencing rashes. V3 said some residents got referrals to see a dermatologist. Some residents rashes did not improve after treatments ordered by the physicians. V3 said some residents are still itchy. V3 said there are currently multiple residents that are experiencing some type of rash but the cause is still unknown.On November 25, 2025 at 1:46 PM, V14 Medical Records/Human Resources said she started taking on the responsibility of making residents' appointments a few weeks ago. V14 said the doctor puts the referral order in the computer system and the nurse then gives V14 the order. V14 said she calls the particular office and lets them know that she has a referral. V14 said she then faxes over all of the required documents to that office. V14 said she waits a few days to get a call back from the doctors office and if she doesn't receive one, then she follows up with a phone call after one week. V14 said she does not have any fax confirmations of R1, and R7-R10's referrals to the dermatologist. V14 said she is still waiting on a call back for R9 and R10. V14 said there was a different staff member that was working at the facility that handled the referrals. V14 said she did not know which doctor this Residents Affected - Some Page 1 of 2 145476 145476 11/25/2025 Oregon Living and Rehabilitation Center 811 South 10th Street Oregon, IL 61061

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some previous staff member sent the referrals to. V14 said that V3 Wound Care Nurse asked her today (November 25, 2025) if R1 and R7 had appointments scheduled to see the dermatologist. V14 said she called the dermatologist office today and made R1 and R7's dermatologist appointments. I had to make those appointment today, they did not have appointments made prior to today.The facility's Comprehensive Person-Centered Care Plans policy reviewed March 21, 2025 shows, A comprehensive, person centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional need is developed and implemented for each resident. Each resident's comprehensive person centered care plan will be consisitent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and/or items included in the plan of care. 145476 Page 2 of 2