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 (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 3 Event ID: 145636 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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)