Inspection·June 28, 2024

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 observation, interview and record review the facility failed to ensure wound dressing changes were performed as ordered by the physician for 2 of 3 residents (R1 and R6) reviewed for quality of care in the sample of 9. Residents Affected - Few The findings include: 1. On 6/28/24 at 10:53 AM, V11 (Wound Care Registered Nurse) performed a dressing change on R6. V11 removed R6's dressing from his left lower leg. There was a large amount of bloody drainage on the two large absorbent pads that were covering the wound. R6's lower legs had multiple open areas present with bright red blood coming from them. On 6/28/24 at 10:53 AM, V11 said that R6's dressing is ordered to be changed every Monday, Wednesday and Friday. V11 said that the wound physician changes the dressing on Wednesdays and he changes the dressings on Monday and Fridays. V11 said that once he does the dressing change, he charts it on the Treatment Administration Record (TAR). R6's May TAR shows an order dated 4/26/24-5/8/24 for: Left Lateral Calf-collagen-cleanse area w/nss (with normal saline), pat dry, apply collagen, house barrier cream around peri wound area then wrap w/ (with) Kerlix, ace bandage and ABD pad dressing three times a week or PRN (as needed). Every day shift every Mon, Wed, Fri for wound care. R6's May TAR shows a new order dated 5/10/24-6/20/24 for: Left Lateral Calf- Collagen/triamcinolone 0.1%-cleanse area w/nss, pat dry, apply collagen and triamcinolone ointment, house barrier cream around peri wound area then wrap w/ kerlix, ace bandage and ABD pad dressing three times a week or PRN. Every day shift every Mon, Wed, Fri for wound care. R6's June TAR shows a new order dated 6/21/24 for: Left Lateral Calf-Collagen-Cleanse area w/nss, pat dry, apply collagen cover with ABD pad then wrap with kerlix three times a week or PRN. Every day shift every Mon, Wed and Fri for wound care. R6's May and June TAR shows that his dressing change was not performed on 5/3/24 (Friday), 5/13/24 (Monday), 5/27/24 (Monday), 6/10/24 (Monday), 6/14/24 (Friday) and 6/24/24 (Monday). On 6/28/24 at 2:02 PM, V11 said that he does not know why so many dressing changes were not signed off on R6's May and June TAR. V11 said that anytime a dressing is changed, it should be documented on the TAR. On 6/28/24 at 12:26 PM, V2 (Director of Nursing) said that all treatments should be documented in the TAR when done. V2 said, If it was not documented, it was not done. R6's Wound Physician notes dated 6/26/24 shows he has a vascular wound measuring 21 cm (centimeters) x 17 cm x 0.1 cm on his left lateral leg. R6's Current Care Plan shows that he has venous stasis ulcers to his left lower leg, posterior aspect with interventions of: Administer treatments as ordered and monitor for effectiveness. The facility's Pressure Injury and Skin Condition Assessment Policy revised on 1/17/18 shows, Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145660 If continuation sheet Page 2 of 5 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 145660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Westchester 2901 South Wolf Road Westchester, IL 60154 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. R1's Wound Physician note dated 4/17/24 shows that she has a new full thickness wound to her right lateral calf measuring 1.2 cm x 0.8 cm x 1.1 cm. The report shows that the wound is an infection and is draining a moderate amount of purulent drainage. The physician ordered ¼ inch gauze packing strips and a gauze island dressing to be applied once daily. R1's Wound assessment dated [DATE] shows the right lateral calf wound was measuring 1.4 cm x 0.8 cm x 0.9 cm. The Wound Assessment shows, Wound depth and undermining is slightly increasing in length since last assessment. Deterioration expected due to hospice care and prognosis R1's April TAR shows an order starting 4/19/24 to 4/24/24 for: R, lateral calf: cleanse with NSS and gently pat dry, loosely pack with iodoform and cover with dry dressing. To be completed daily and as needed. Every day shift for wound care. R1's April TAR shows that this treatment was not performed on 4/20/24 and 4/21/24 (Saturday/Sunday). R1's April TAR shows a new order starting 4/25/24 to 5/13/24 for: Right lateral calf-iodoform-cleanse area with NSS and gently pat dry, loosely pack with iodoform and cover with dry dressing. To be completed daily and PRN. Every day shift for wound care. R1's April and May TAR shows that this dressing was not performed on 4/27/24, 4/28/24, 4/29/24 (Saturday/Sunday/Monday), 5/2/24, 5/3/24 (Thursday/Friday), 5/5/24 (Sunday) and 5/12/24 (Sunday). On 6/28/24 at 2:02 PM, V11 said that he does not know why so many dressing changes were not signed off on R1's April and May TAR. V11 said that anytime a dressing is changed, it should be documented on the TAR. V11 said that R1's Hospice nurse would perform dressing changes when she visited R1. R1's Hospice Communication Log shows that the Hospice Nurse did not see R1 on any of the above days besides 5/3/24. On 6/28/24 at 12:26 PM, V2 (Director of Nursing) said that all treatments should be documented in the TAR when done. V2 said, If it was not documented, it was not done. R1's Care Plan shows that she has an infectious wound on her right lateral calf with interventions of: Wound Treatment as ordered. The facility's Pressure Injury and Skin Condition Assessment Policy revised on 1/17/18 shows, Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145660 If continuation sheet Page 3 of 5 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 145660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Westchester 2901 South Wolf Road Westchester, IL 60154 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on observation, interview and record review the facility failed to perform pressure ulcer dressing changes as ordered by the physician for 2 of 3 residents (R1 and R2) reviewed for pressure ulcers in the sample of 9. This failure resulted in R1 developing an infected right heel pressure wound. Residents Affected - Few The findings include: 1. R1's Wound Assessment Report dated 2/4/24 shows that she admitted to the facility with an unstageable pressure ulcer on her right heel measuring 5.5 cm (centimeters) x 6.8 cm x 0.1 cm with light serosanguineous (pink thin fluid secreted from wounds in the healing process) drainage present. R1's Wound Physician note dated 4/17/24 shows that R1's right heel pressure ulcer was now a stage 4 pressure ulcer measuring 8.5 cm x 5 cm x 1.9 cm. R1's right heel pressure ulcer had heavy purulent (thick pus like drainage from an infection) drainage and the wound progress was not at goal. That same report shows that Metronidazole (antibiotic) 250 mg crushed and sprinkled on wound daily for odor was ordered on 4/3/24 for 30 days. R1's Right Heel Wound Culture Report collected 4/19/24 shows moderate growth of escherichia coli, proteus mirabilis and enterococcus faecalis. R1's Treatment Administration Record (TAR) for April shows an order dated 4/3/24-4/14/24 for: Right heel-Dakins 0.125%-cleanse area with NSS (normal saline), pat dry, pack with Dakins wet to moist gauze, cover with ABD pad, and wrap with kerlix twice daily or as needed. Every day and evening shift for wound care. R1's TAR for April and May show an order dated 4/14/24-5/13/24 for: Right heel-Dakins 0.125%-Cleanse area with NSS, pat dry, pack with Dakins wet to moist gauze, cover with ABD pad, and wrap with kerlix twice daily or as needed. Every day and night shift for wound care. R1's April and May TAR shows that these dressings were not performed on 4/5 (Friday (Fri) evening), 4/9 (Tuesday (Tues) evening), 4/13 (Saturday (Sat) evening), 4/14 (Sunday (Sun) day), 4/15 (Monday (Mon) night), 4/17, 4/18, 4/19 (Wed, Thurs, Fri night), 4/20, 4/21 (Sat/Sun day), 4/22, 4/23, 4/24, 4/25 (Mon-Thurs night), 4/27 (Sat day and night), 4/28, 4/29 (Sun/Mon day), 5/2, 5/3 (Thurs/Fri day), 5/5 (Sun day), 5/6 (Mon night), 5/8 (Thurs night), 5/11 (Sat night) and 5/12 (Sun day and night). On 6/28/24 at 2:02 PM, V11 said that he does not know why so many dressing changes were not signed off on R1's April and May TAR. V11 said that anytime a dressing is changed, it should be documented on the TAR. V11 said that R1's Hospice nurse would perform dressing changes when she visited R1. R1's Hospice Communication Log shows that the Hospice Nurse did not see R1 on any of the above days besides 5/3/24. On 6/28/24 at 12:26 PM, V2 (Director of Nursing) said that all treatments should be documented in the TAR when done. V2 said, If it was not documented, it was not done. On 6/28/24 at 2:28 PM, V12 (R1's Wound Physician) said R1 was receiving treatment for a wound odor and increased drainage of her heel pressure ulcer. V12 said that they did a culture of the wound and it came back showing an infection. V12 said that it is important to do dressing changes as ordered. V12 said that if dressing changes are not done, the wound could become infected. V12 said that if the wound already had an infection and they were not done, that could keep the bacteria in the wound and limit healing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145660 If continuation sheet Page 4 of 5 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 145660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Westchester 2901 South Wolf Road Westchester, IL 60154 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 R1's Care Plan show that she was on antibiotic therapy, Bactrim DS related to an infection of her right heel wound initiated on 4/16/24 with intervention to include: Wound treatment applied as ordered. Level of Harm - Actual harm Residents Affected - Few The facility's Pressure Injury and Skin Condition Assessment Policy revised on 1/17/18 shows, Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration . 2. R2's Wound Assessment Report dated 3/28/24 shows that she admitted to the facility with an unstageable left trochanter pressure ulcer measuring 6 cm x 5.5 cm x 0.1 cm. On 6/28/24 at 10:35 AM, V11 performed a dressing change to R1's right hip pressure wound. V11 removed the dressing and there was a small open area on her right hip present. R1's May TAR shows an order dated 5/3/24-5/28/24 for: Left hip-collagen with silver/acetic acid 0.25%-cleanse area with acetic acid, pat dry, apply silver collagen sheet and cover with dry dressing every two days or as needed. Every day shift every 2 days for wound care. R2 did not receive a dressing change for 8 out of the 13 ordered dressing changes. R2's May TAR shows an order dated 5/30/24-6/13/24 for: Left hip- Collagen with silver-Cleanse area with acetic acid, pat dry, apply silver collagen and cover with dry dressing daily or as needed. R2 did not receive a dressing change for 7 out of the 13 ordered dressing changes. R2's June MAR shows an order starting 6/14/24 for: Left hip-Collagen-Cleanse area with acetic acid, pat dry, apply collagen sheet and cover with dry dressing daily or as needed. Every day shift for wound care. R2 did not receive 9 out of 15 ordered dressing changes. On 6/28/24 at 2:02 PM, V11 said that he does not know why so many dressing changes were not signed off on R2's May and June TAR. V11 said that anytime a dressing is changed, it should be documented on the TAR. On 6/28/24 at 12:26 PM, V2 (Director of Nursing) said that all treatments should be documented in the TAR when done. V2 said, If it was not documented, it was not done. The facility's Pressure Injury and Skin Condition Assessment Policy revised on 1/17/18 shows, Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145660 If continuation sheet Page 5 of 5