Health inspection·June 28, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the Physician and the Power of Attorney when changes were identified for R1 relating to diabetic ulcers of R1's right great toe. R1 is one of three residents reviewed for diabetic ulcers in a sample list of six residents. Findings include: The Physician's Order Sheet (POS) dated June 2024 lists the following diagnoses for R1: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Chronic Diastolic (Congestive) Heart Failure. The Minimum Data Set (MDS) assessment dated [DATE] documents R1's mental status is moderate cognitively impaired. The same MDS documents R1 needs staff assistance for all activities of daily living and R1's showers are given to him twice a week by staff. On 5/21/24 R1's shower sheet stated R1's right great toe has a black sore. V5 CNA (Certified Nurse Assistant) reported this information to the Charge Nurse V6, RN (Registered Nurse). R1's progress note dated 5/21/24 at 10:16 AM states Skin/Wound Note: R1 has open area to Right toe and area blackened to Right toe. Bandage applied. Redness to (buttocks) noted. No progress notes document R1's physician or POA (Power of Attorney) were notified of the change in R1's skin condition on 5/21/24. V2, Director of Nurses and V4, Wound Nurse stated on 6/26/24 at 2:30 pm they were not aware of R1's shower sheet or progress note about R1's right great toe having an open area. Interview with V5, CNA on 6/27/24 at 10:46 am stated Yes, I remember doing (R1's) shower and finding the blacken area on his right big toe. I marked it down on my shower sheet and reported to the Charge Nurse V6. V6 brought in some ointment and put it on his toe with a bandage. Interview with V6, RN on 6/27/24 at 10:50 AM stated I am sorry I don't recall the incident; I could not say what happened don't recall. The facility's form titled Wound Weekly Evaluation-Non-Pressure dated 6/18/24 at 2:09 PM documents a wound to R1's right great toe identified on 6/10/24. The evaluation states under Section A Communication Notification of Clinician was 6/10/24 at 9:00 PM and date of family notification was 6/12/24. V4, RN/Wound Nurse stated on 6/26/24 at 1:30 PM V4, RN is the one who completed the form and did not contact the family until 6/12/24. V4 did not have a reason for the late notification. Facility policy titled Monthly Skin Checks revision date 6/2020 states It is the policy of the Page 1 of 3 145636 145636 06/28/2024 Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920

F 0580 Level of Harm - Minimal harm or potential for actual harm facility to complete monthly skin checks by the licensed nurses for all residents. The medical practitioner and resident representative will be notified of any newly identified issues. Treatment orders will be obtained, and new treatments started as ordered. Residents Affected - Few 145636 Page 2 of 3 145636 06/28/2024 Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920

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 notify the physician of a new diabetic foot ulcer, obtain a treatment order, and complete wound assessments for multiple days after the wound was found for one of three residents (R1) reviewed for diabetic ulcers in a sample list of six. Residents Affected - Some Findings include: The Physician's Order Sheet (POS) dated June 2024 lists the following diagnoses for R1: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Chronic Diastolic (Congestive) Heart Failure. The Minimum Data Set (MDS) assessment dated [DATE] documents R1's mental status is moderately cognitively impaired. The same MDS documents R1 needs staff assistance for all activities of daily living to include showers. R1's 5/21/24 shower sheet states R1's right great toe has a black sore. V5 CNA (Certified Nurse Assistant) reported this information to the Charge Nurse V6, RN (Registered Nurse). R1's progress note dated 5/21/24 at 10:16 AM states Skin/Wound Note: R1 has open area to right toe and area blackened to right toe. Bandage applied. Redness to (buttocks) noted. No further progress notes document R1's physician was notified of the change in R1's skin condition on 5/21/24. There is no additional documentation about R1's diabetic ulcer on his right great toe until 6/11/24 whenV4, Wound Nurse completed a Weekly Skin Check for R1 and the form states R1 has a new area located on his right great toe. R1's Medical Record documents R1 was seen by V11 Physician on 6/12/24 and an x-ray was obtained of R1's right great toe and R1 was diagnosed with Osteomylitis. R1's Medical Record documents R1 was started on Augmentin 875-125 milligrams(mg) on 6/12/24. Progress notes for R1 dated 6/17/24 document R1 has increased edema and redness and the physician was notified. R1's medical record documents R1 was hospitalized on [DATE] for IV (intravenous) antibiotics. V7, Physician stated in interview on 6/28/24 at 10:47 AM that R1 was noncompliant with R1's diet and had a history of eating high sugar food continuously. V7 also stated R1 wanted to keep his shoes on all the time. V7 stated R1 was scheduled for right great toe amputation on 6/27/24. The Facility's policy titled Skin Checks revision date 3/2022 documents It is the policy of the facility to complete weekly checks by the licensed nurses for all residents. At the time the wound or skin condition is identified, the provider and the resident representative will be notified of the newly identified issues. Treatment orders will be obtained, and new treatment started as ordered. V2, Director of Nurses and V4, RN Wound Nurse stated on 6/26/24 at 2:30 pm they were not aware of R1's shower sheet or progress note about R1's right great toe having an open area on 5/21/24. V2 confirmed during the interview R1 did not receive any treatments due to not knowing the diabetic ulcer was present and the doctor not being notified. V2 stated we dropped the ball with the issues of (R1.) 145636 Page 3 of 3