Inspection·December 6, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few two-person, mechanical transfer lift out of bed. V5 stated that V5 assesses R1's skin whenever V5 is performing incontinence care or bathing of R1. V5 stated that if V5 sees a new skin opening on a resident, V5 must report it right away to the nurse. This surveyor asked V5 that with the observation of this surveyor and V5 viewing R1's sacral pressure ulcer wound with barrier cream on it (on 12/5/2025 at 10:34 AM), was this the first time that V5 had seen R1's sacral wound, and V5 stated no. V5 stated that V5 saw R1's open sacral wound yesterday (12/4/2025) with the white barrier cream on it and reported it to the nurse. V5 stated that V5 forgot the name of the nurse, but R1's sacral skin was open and there was white cream over it on 12/4/2025. V5 reiterated again that V5 could not recall who the nurse was that V5 reported R1's sacral wound to on 12/4/2025. This surveyor informed V5 that surveyor will identify the nurse working with R1 on 12/4/2025 and speak with the nurse about V5 reporting R1's sacral pressure ulcer wound. V5 then stated that V5 did not report it to the nurse and V5 doesn't want to be lying. V5 stated that when V5 saw R1's sacral open wound on 12/4/2025 with barrier cream on it, V5 stated, I (V5) assumed that someone had reported it to the nurse, and V5 did not report R1's sacral skin opening. On 12/5/2025 at 2:27 PM, V8 (LPN) stated that V8 works different floors in the facility but, when V8 works on R1's floor, R1 is V5's regularly assigned resident. V8 stated that skin assessments are done weekly by the nurse, and they are done daily by the CNA during incontinence care and bathing care. V8 stated that if a CNA finds anything abnormal with the resident's skin, the CNA must report it right away to the nurse. V8 stated it could be a red spot on the skin, skin turgor being poor or any opening in the skin. V8 stated that the importance of the direct care staff (CNAs) reporting it to the nurse is so the nurse can follow up immediately before it gets worse. V8 stated that the nurse will contact the wound care team and the doctor so they will start treatment as ordered. V8 stated that the staff does not want the skin opening to advance any further if untreated. V8 stated that general precautions to prevent pressure ulcer wounds from forming are to turning and offloading so pressure is relieved on the body from being in one position for too long. When asked prior to today, 12/5/2025, had it been reported to V8 that R1 had a sacral pressure ulcer, V8 stated yes but that V8 can't remember the date or exactly what was said. V8 stated that if there is a new skin change, like an open pressure ulcer wound, reported to V8, V8 would document it in the resident's HER. This surveyor informed V8 that upon review of R1's progress notes and skin assessments prior to 12/5/2025, there is no documentation that R1 had a new skin opening. V8 then stated that V8 is really not sure yes or no if it was reported to V8 about R1's sacral pressure ulcer and that V8 just can't remember.On 12/5/2025 at 11:55 AM, V14 (LPN, Wound Care Nurse) stated that V14 was made aware today, 12/5/2025, of R1's open area to the sacrum and went and assessed R1. V14 stated that the sacral wound measured 4.8 centimeters (cm) in length, 3.8 cm in width, and 0.1 cm in depth with slight serosanguineous drainage, and is a stage 2 pressure ulcer. V14 stated that V14 notified R1's doctor who ordered for a cleansing with normal saline and a foam dressing with a daily and whenever needed change. V14 stated that the dry foam dressing will allow for urine or stool not to contaminate the wound.On 12/5/2025 at 3:18 PM, V15 (Wound Care Coordinator) stated that for when a new skin alteration is noted on a resident, the floor nurse is notified, and the floor nurse will then notify V15. V15 stated that V15 (or other wound care nurse, V14) will do a head to toe skin check. V15 stated that skin alterations can be breaks in the skin, rashes, or anything that looks abnormal or the resident did not have previously. V15 stated that the nurse will call the doctor to see what treatment needs to be in place. V15 stated that it's important to start this process immediately so there is not worsening skin problem want to skin intact not get any worse. V15 stated that CNAs are constantly looking at skin and must notify the floor nurse if there are changes in a resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145429 If continuation sheet Page 2 of 4 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 145429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few skin. V15 stated that R1's sacral pressure wound was not reported to V15 prior to 12/5/2025.On 12/5/2025 at 3:27 PM, V3 (Assistant Director of Nursing, ADON) stated that V2 (Director of Nursing) is currently on vacation and that V3 is responsible for the nursing department and staff. V3 stated that the importance of a CNA directly informing the floor nurse when a new skin opening is noted on a resident, like R1's sacral wound, is that it's extremely important because (skin) breakdown happens so fast. It's effective communication V3 stated that when a new skin opening is reported to the floor nurse, the floor nurse will notify the wound care coordinator (V15) who will perform a full head to toe assessment. V3 stated that the nurse will notify the doctor of the findings and receive treatment orders to be rendered. V3 stated that every day, CNAs are looking at residents' skin during activities of daily living care and bathing care and are a crucial component to identifying changes in a resident's skin condition. V3 stated that a foam dressing treatment order for a sacral pressure ulcer can protect the wound as it heals and help with pain as well. V3 stated that urine and feces can irritate or burn an open sacral pressure ulcer wound and also prevents sheering of the sacral skin. R1's WASA (Wound Area Severity Assessment) Form, effective 12/5/2025 at 11:36 am (after this surveyor's observation on 12/5/2025 of R1's sacral pressure ulcer), V14 (LPN, Wound Care Nurse) documents, in part, that R1 has a wound to the sacrum assessed as a pressure ulcer, stage 2 with size of 4.8 cm in length, 3.8 cm in width, and 0.1 cm in depth. R1's Shower/Bath Reports from November and December 2025 were reviewed with CNA documentation to the task question of during bath/shower, is there any new skin issues, and No New Skin Abnormality is documented on 12/4/2025, 11/30/2025, and 11/27/2025.R1's Progress Notes, from 8/22/2025 at 5:52 PM to 12/5/2025 at 11:15 AM, indicate no documentation of R1's sacral pressure ulcer (new skin opening). R1's Treatment Administration Record for December 2025 documents, in part, only one wound care treatment, dated 12/5/2025, for cleansing with normal saline and then apply a foam dressing adhesive 4 x 4 (4 inches by 4 inches) pad to sacral topically every day shift and whenever needed for wound care. R1's Braden Scale, dated 11/22/2025, documents, in part, that R1 is scored as 14 which indicates that R1 is at moderate risk of skin breakdown.R1's Care Plan, initiated 8/22/2025, documents, in part, a focus of R1 has potential for alteration in skin integrity with care. R1's Care Plan, initiated 8/23/2025, documents, in part, a focus of R1 requiring bowel and bladder support due to R1's bladder and bowel incontinence, decreased mobility, and CVA (cerebral vascular accident) with an intervention to: Check skin daily with cares. Report abnormalities or changes to the nurse.R1's Care Plan, initiated 8/23/2025, documents, in part, a focus of R1 has an ADL functional performance deficit where R1 is unable to turn and reposition self in bed without physical assistance from staff with interventions of assist R1 with check skin for changes during bathing and to assist R1 with ADL tasks as needed.R1's Turning and Repositioning Program Quarterly Review, dated 11/25/2025, V13 (Restorative Nurse, LPN) documents, in part, that there has been no change in R1's condition since last review and that turning and repositioning interventions have been effective at helping to manage or maintain R1's skin status. Facility policy titled Prevention and Treatment of Pressure Injury and Other Skin Alterations dated 3/2/2021 documents, in part, Policy: 1. Identify residents at risk for developing pressure injuries. 2. Identify the presence of pressure injuries and/or other skin alterations. 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Procedure: 1. Identify residents at risk for Developing pressure Injuries utilizing the Braden Scale . 3. Pressure injuries, Venous, Arterial, Diabetic ulcers and DTPI (Deep Tissue Pressure Injury) will be assessed weekly and as needed by facility staff or consulting clinician, by utilizing a WASA or other consulting clinicians' evaluation . 6. Complete a Comprehensive Pressure Injury (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145429 If continuation sheet Page 3 of 4 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 145429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621 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)

F 0686 Evaluation for identified pressure injuries . 8. At least daily, staff should remain alert for potential changes in the skin condition during resident care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145429 If continuation sheet Page 4 of 4