Inspection·October 27, 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 observation, interview and record review the Facility failed to provide physician ordered treatments for three of three Resident's (R1, R2 and R3) reviewed for wound care in a sample of three. Residents Affected - Few Findings include: Facility Wound Treatment Management Policy, revised 8/19/24, documents: to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; and wound treatments will be provided in accordance with physician orders including the cleansing method, type or dressing and frequency of dressing change. Facility Physician/Practitioner Orders, revised 12/13/23, documents: the attending physician/practitioner may include, but is not limited to wound care. The Facility Administrator Job Description, dated 6/2021, documents the position purpose as leading, guiding and directing the operations of the healthcare facility in accordance with local, state and federal regulations standards and established facility policies and procedures to provide appropriate care and services to residents. The Facility Wound/Skin Log, dated 9/24/24, documents: R1's Lymphedema to R1's Left Lower Shin and Right Lower Shin; R2's Left Lateral Abdominal Fissure and R3's Right Dorsal Trauma/Injury. The Resident Council Minutes, dated 7/7/24 document concerns with day to day nursing care varies and would like care needs to be more consistent and would like (V7/Wound Nurse's) orders for care followed by other nurse caring for residents. R1's Treatment Administration Records, dated 10/1/24 through 10/25/24, do not document completion of Physician Orders for: monthly skin assessments (Braden Scale) on 10/6/24; cleanse Left and Right below the Knees with surgical cleanser (Antiseptic Skin Cleanser) and pat dry every day shift for wound care on 10/5/24, 10/6/24, 10/8/24, 10/9/24, 10/14/24 and 10/23/24; cleanse Left Lower Shin with surgical cleanser and apply dry dressing (Petroleum Gauze Dressing) and cover with a wrap (Gause Dressing) every day shift for 10/5/24 and 10/6/24; cleanse Left Medial thigh with wound cleanser and apply dry dressing (Petroleum Gauze Dressing) and cover with a wrap (Gause Dressing) every day shift for 10/5/24, 10/6/24, 10/8/24 10/9/24 and 10/14/24; ensure Left Lower Shin dressing is clean and dry every day shift for wound care for 10/5/24 and 10/6/24; apply barrier cream to Buttocks and Sacrum daily every shift on 10/5//24, 10/6/24, 10/8/24 and 10/14/24; and ensure dressing (Antimicrobial Fabric) is intact in Ankle area every shift for 10/5/24, 10/6/24, 10/8/24 and 10/14/24. (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 10/27/2024 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)