Inspection·February 5, 2026

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 document a physician's order for treatment of a skin tear and to obtain physician's order for monitoring of the wound until it was healed for 1 (R1) of 3 residents reviewed for wounds in a sample of 8.R1's admission record dated 2/4/26 documents an admission date of 1/2/26. Same admission record documents diagnoses including but not limited to end stage renal disease, type II diabetes, and epilepsy.R1's minimum data set/MDS dated [DATE] documents R1 has a brief interview for mental status/BIMS score of 11 indicating resident has moderately impaired cognition.R1's most recent care plan undated has a focus area for R1 indicating he has potential for impairment of skin integrity dated 2/2/26. Interventions for this focus area include but aren't limited to avoid scratching and keep hands and body parts from excessive moisture and to keep fingernails short dated 2/2/26.R1's skin issue risk assessment form dated 1/16/26 documents R1 had obtained a skin tear to his right forearm the same day by getting his right arm caught in between two rails in the bathroom that were near the toilet. The same form documents the treatment administered by V10; Registered Nurse (RN) was she cleansed the skin tear with normal saline and applied three steri-strips. Same form documents V8, Nurse Practitioner (NP) was notified same date, but not that any orders were received for treatment/monitoring of the skin tear.R1's discontinued and completed orders for the month of January 2026 do not document an order for treatment/dressing to the skin tear to R1's right forearm obtained on 1/16/26 or an order to monitor the area for signs/symptoms of infection until healed. R1's current physician order sheets dated 2/4/26 do not document any such order.R1's treatment administration record (TAR) for the month of January does not contain any documentation any treatments were done to a skin tear of the right forearm or to monitor the skin tear daily for healing or signs/symptoms of infection.On 2/2/26 at 155 PM, R1, after returning from dialysis, was observed lying in bed covered with a sheet up to his waist and a long sleeve shirt on his torso. When asked R1 about the scabbing/scarring area to his right forearm R1 states he doesn't remember how he obtained the injury. Same wound of right forearm appears to be healing well without any signs/symptoms of infection. On 2/4/26 at 9:42 AM, V10, Registered Nurse (RN) stated R1 had obtained a skin tear to his right forearm while using the bathroom. V10 stated she did not actually see R1's skin break but did see his right forearm caught between the two bars in the bathroom. V10 stated she does remember cleaning the skin tear with normal saline and applying three steri-strips to it. V10 stated she notified R1's power of attorney (POA), nurse practitioner (NP), and facility administration of the R1's wound and how he had obtained it. V10 stated the NP had indicated the dressing she had done on the R1's skin tear was appropriate. V10 stated she did not document the order for the dressing change/treatment to the skin tear and did not obtain an order to monitor the area until healed for signs/symptoms of infection and/or not healing. V10 stated she did not think it was necessary to write an order for the above because it was common sense and a one-time need for a dressing/treatment.On 2/4/26 at 10:09 AM, Residents Affected - Few (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: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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)