Inspection·September 14, 2023

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 2. R2's Wound Evaluation Management Summary, dated 8/16/23, and signed by V11 (Wound Physician) documents R2 was seen on 8/16/23 by V11 for a chief complaint of a wound on his left lateral fifth toe. A new order for skin prep to the wound was recommenced at that visit. Residents Affected - Few R2's Treatment Administration Record, dated 9/1/23-9/30/23, documents R2 has a Treatment order to Apply Betadine (topical antiseptic) to left second and fourth toes and left lateral fifth toe daily and PRN (as needed) every day shift for wound care. This order has a start date of 8/26/23. On 9/11/23 at 1:15 PM, V4 (Licensed Practical Nurse) completed R2's wound treatment while R2 remained in bed. V4 cleansed R2's toes and applied Betadine to the 2nd and 4th toe on R2 left foot. A pencil eraser sized scab was noted on the side of R2's left foot (Lateral 5th toe location). V4 stated, There is not a treatment for that site. It has been there for a couple of weeks but there is nothing in place for that one. V4 completed the drying of R2's toes and reapplied a heel protection boot to his foot, without completing any treatment to the left lateral fifth toe site. R2's current care plan, dated 2/2/23, documents, The resident has actual impairment to skin integrity of the left fourth toe and second toe related to diabetic. This care plan does not document any revision since the development of a new wound on R2's left lateral fifth toe. On 9/13/23 at 1:30 PM, V8 (Assistant Director of Nursing/ Wound Nurse) confirmed R2 has a treatment order for his left lateral fifth toe. V8 stated, The Betadine treatment should be done to all three sites when doing his wound care not just the second and fourth toes. On 9/14/23 at 10:10 AM, V16 (Care Plan Coordinator) stated, Some areas of the care plan are done by me and some by other staff. The wound nurse (V8) does the wound care plans. New wound sites should be added to the wound care plan. Anything new for residents should be updated on the care plan within 24 hours. Both CNA's (Certified Nursing Assistants) and Nurses use and look at the care plans for resident cares. Based on observation, interview, and record review the facility failed to immediately assess a newly acquired wound, implement new skin interventions, obtain a treatment order upon wound identification, revise a wound care plan, and follow physician orders for wound care for two of three residents (R2, R3) reviewed for wounds in the sample of five. Findings include: The facilities Wound Treatment Manage policy dated, 8/22/2023, documents, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based (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: 145600 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 145600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab & Nursing of Canton 2081 North Main Street Canton, IL 61520 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)