Health inspection·July 16, 2025

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 treatment and services for a non-pressure abdominal wound. This failure affects one resident (R1) out of three reviewed for skin conditions and treatments on the sample list of five. Findings include: R1's Nurses Notes dated 7/2/2025 at 12:30 PM documents the nurse on duty was notified by the night shift nurse that this resident (R1) had an open area noted to her left side. The open area was noted to be 1 centimeter by 3 centimeters area to left lower abdomen. R1's Nurse Practitioner was notified and the open area was cleaned with wound wash, covered with xeroform and covered with border foam and the treatment will continue until healed. R1's current Physician Order Sheet dated for July 2025 documents a physician order for R1 to receive a treatment for an abdominal wound described as, Cleanse area to left lower abdomen with wound wash/normal saline, apply Xeroform dressing and cover with border foam daily, until healed, every day shift. This physician ordered treatment was dated as ordered 7/2/25, and treatment to begin on 7/3/25. On 7/15/25 at 11:15 AM, R1 had an open wound on her lower left abdomen approximately 2.5 centimeters diameter which was partially scabbed and had a moist reddened center. There was not a dressing present on R1's abdominal wound. On 7/15/25 at 11:15 AM, V2, Director of Nursing, confirmed there was no dressing on R1's abdominal wound stating he did not see a dressing. V2 further stated the wound was self-inflicted from R1 scratching and picking at her skin. R1's Treatment administration Record dated for July 2025 documents R1's abdominal wound treatment was not completed on 7/14/25 by way of a blank under this date with no nurse initials to document the treatment was completed. On 7/16/25 at 10:40 AM, V2, Director of Nursing, stated and confirmed the treatment for R1's abdomen was a current treatment on 7/14/25 and should have been completed and documented. At 4:00 PM, V2 stated the nurse responsible for the wound treatments (V9, Licensed Practical Nurse/ Wound Nurse) had been DNR'd (Do Not Return to work) due to not completing the wound treatment according to the physician order on 7/14/25. Residents Affected - Few Page 1 of 2 145772 145772 07/16/2025 Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 and services to aid in the healing of a pressure ulcer. This failure affects one resident (R1) out of three reviewed for skin issues and treatments on the sample list of five. Findings include: R1's current Physician Order Sheet dated for July 2025 documents treatments for R1's pressure ulcer on the left heel as, Cleanse area to left heel with wound wash or normal saline, apply collagen to wound bed and cover with border foam, every day shift and Float heels on pillow at all times. On 7/15/25 at 11:15 AM, R1 had a dressing on her left heel that was dated 7/13 (2025). R1 did not have a pillow present under her legs or feet to float her heels off of the bed surface. On 7/15/25 at 11:15 AM, V2, Director of Nursing, confirmed the date on R1's heel dressing was 7/13. V2 further confirmed there was no pillow present to float R1's heels off of the bed surface. V2 stated the wound on R1's left heel was a pressure ulcer. R1's Treatment Administration Record dated for July 2025 documents the dressing change for R1's heel pressure ulcer was not completed on 7/14/25 by way of a blank under this date with no nurse initials to document the dressing was completed. R1's Treatment Administration Record dated for June 2025 likewise documented the dressing change for R1's heel pressure ulcer was not completed on 6/25/25 and 6/26/26. On 7/16/25 at 10:40 am, V2, Director of Nursing, confirmed the dressing change order and order to float R1's heels with a pillow were both current orders and should have been completed and documented on 7/14/25. On 7/16/25 at 4:00 PM< V2, Director of Nursing, stated the nurse responsible for the dressing change for R1's heel (V9, Licensed Practical Nurse/ Wound Nurse) had been DNR'd (Do Not Return to work) because V2 takes the wound treatments very seriously. Residents Affected - Few 145772 Page 2 of 2