Health 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 Page 1 of 2 145600 145600 09/14/2023 Loft Rehab & Nursing of Canton 2081 North Main Street Canton, IL 61520

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders, or the assigned licensed nurse in the absence of the treatment nurse. This same policy also documents Treatments will be documented on the Treatment Administration Record. The facilities Notification of Changes Policy dated, 12/13/22, documents, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facilities Care Plan Revisions Upon Status Change policy, dated 1/25/23, documents The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed and revised as necessary when a resident experiences a status change. 1. R3's Skin and Wound Evaluation dated, 9/8/23, documents R3's wound was found on 9/7/23, but not evaluated until 9/8/23. The same form documents the area is a blister to the rear right malleolus measuring 0.2 cm (centimeters), length of 0.4 cm, and width 0.8 cm, with a wound bed that contains slough and light serous exudate. R3's Initial Wound Evaluation and Management Summary dated, 9/13/23, and signed by V11 (Wound Physician) documents, Diabetic wound of the right, posterior, upper heel full thickness. This same form documents, Nurse had listed this as posterior ankle, but it does involve the upper posterior calcaneal fat pad and would be considered heel site. R3's care plan dated, 8/28/23, documents, The resident has potential skin integrity of the (right heel r/t (related to) immobility.) This same care plan does not document any revision or new interventions after the heel wound was identified on 9/7/23. R3's physician order dated, 7/28/23, documents orders to Float heels on pillow or use (heel protectors) for pressure relieving every shift for wound care. On 9/11/23 at 11:35 am, R3 was sitting in her wheelchair in her room. R3's left and right heels were observed for 15 minutes resting on R3's foot petals on her wheelchair. R3 had nonslip socks on at this time. R3's (heel protectors) were not on R3's feet and were located on R3's side table. On 9/11/23 at 12:20 PM, R3 was in her room in R3's wheelchair eating lunch. R3 did not have her heel protectors on. R3 stated, I am supposed to wear my heel protectors, but staff doesn't always put them on me, and I need them on for the hole on my right foot. On 9/11/23 at 12:35 PM, V8 (Assistant Director of Nursing/Wound Nurse) stated, Staff (unknown) reported to me on 9/7/2023 that (R3) had an area to the back of her right ankle. I was very busy and I wear multiple hats, so I didn't evaluate the wound or notify the doctor (V7, R3's Physician) until 9/8/2023. V8 confirmed that no new interventions were put into place when R3's wound was identified on 9/7/23 and that R3 did not receive a wound treatment until 9/8/23. V8 stated, (R3) should always have her (heel protectors) on while in her wheelchair. 145600 Page 2 of 2