Health inspection·February 28, 2024

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 Based on interview and record review, the facility failed to follow a physician treatment order for one resident (R1) reviewed for wound treatment orders in a sample of three. Residents Affected - Few Findings Include: The facility's Pressure Injury and Skin Condition Assessment Policy, dated 1/17/18, documents: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries, and other ulcers and assuring interventions are implemented. 18. Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. R1's diagnoses include: Personal history of other malignant neoplasm of skin, varicose veins of right and left lower extremities, non-pressure ulcer of right and left lower extremities, excoriation (skin picking) disorder, end stage renal disease. R1's Treatment Administration Record/TAR dated 10/2023 documents: Treatment to bilateral lower extremities/BLE: Cleanse wounds to BLE with wound cleanser, pat dry, apply calcium alginate to open areas, cover with unna boots and wrap with kerlix and ace wraps. Every day shift every Wednesday, Saturday for wound care per (V6 Wound Care Physician) related to Encounter for change or removal of nonsurgical wound dressing. (Internet definition for unna boot, dated 2/2024 documents: An Unna boot is a compression dressing made by wrapping layers of gauze around your leg and foot. It is often used to protect an ulcer or open wound. The compression of the dressing helps improve blood flow in your lower leg.) Review of R1's 10/2023 TAR indicated there were no staff signage for treatment care for R1 on Wednesday 10/18/23 or on Saturday 10/21/23 to indicate wound care had been done for R1's left foot wound. On 2/16/24 at 12:25pm, V3 Assistant Director of Nursing/ADON/Infection Control Preventionist stated that in October 2023, R1 had scheduled wound treatments; (noted treatments scheduled for Wednesdays and Saturdays); stated that R1 had a wound on his left foot between great toe and second toe; and stated that R1 liked to pick at his lower extremities. On 2/28/24 at 11:10am, V4 Minimum Data Set/MDS/Care Plan Coordinator, confirmed that R1's Treatment Administration Record/TAR for October 2023 indicated no treatment sign offs by staff for 10/18/23 or 10/21/23 prior to 10/25/23 when maggots were noted in R1's left foot wound and stated I notified the appropriate staff and documented about (R1's) infection and about the foul odor on 10/18/23. Not (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: 145486 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 145486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Spring Valley 1300 North Greenwood Street Spring Valley, IL 61362 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)