Inspection·July 25, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some outbreak status through 7/24/24. On 7/23/24 at 12:42 PM, V4 stated that on 7/2/24, V4 came to work for her 6 pm - 6am shift but went home early on 7/3/24 because she was sick. V4 stated that she was informed that V12 was sitting in a common area where some residents were also sitting. V4 stated later that morning she had received a text picture from V11 (Night Shift Nursing Supervisor) showing that V12 had tested positive for COVID-19. On 7/24/23 at 10:54 AM, V4 stated that she did not test any residents as she should have that may have been exposed to V4 on 7/2/24 - 7/3/24. V4 stated that she only tested some residents on 7/10/24 after the facility had their 2nd positive COVID-19 case. On 7/24/24 at 11:50 AM, V4 stated she did not know what residents were in the common area when V12 was sitting there, and it would have made the most sense if she had tested all of the residents from that area (R2-R56) but she did not. V4 stated she contacted the Will County Health department 3 days after the 2nd positive case, (7/13/24) and was instructed that she should have tested everyone. On 7/24/24 at 10:15 AM, V4 stated that she tested some staff but did not start documenting the testing until 7/15/24. At 10:52 AM V4 said that there were too many people for her to track and she did not follow up on the tracking and documentation because she trusted everyone would come to her as they were told. On 7/24/24 at 12:46 pm, V2 DON (Director of Nursing) stated to her knowledge V12 was in the common area around unknown residents on 7/3/24. V2 stated that it is her expectations that V4 should test and track all persons that came in contact with V12. V2 stated that R2 - R56 should have been tested. V2 stated that V4 should have a line list for both staff and residents tracking from the 1st day exposed (day 0) and testing on 7/4/24 (day 1), 7/6/24 (day 2), and 7/8/24 (day 3). V2 stated that R2 - R56 were not tested on those days at all. V2 stated that she has no documentation, nor any knowledge of any staff being tested after being in contact with V12 on 7/2/24 - 7/3/24. V2 stated that any staff that had been in close contact with V12 should have been tested 3 times and that it is the responsibility of the Infection Preventionist Nurse to have staff tested and if they do not, they should be removed from the schedule. At 2:12 PM, V2 stated that R2 -R56 should have been put on at least EBP (enhanced barrier precautions) once they were possibly exposed, and they should have stayed on the precautions for the duration of the testing time. V2 stated that none of the residents were put on any type of precautions during this time. V4 stated that it is her expectation that V4 put R2 - R56 on those precautions. V2 stated that it is the facility's policy to test the residents and staff after a positive exposure or possible exposure and the testing is recommended on the 1st 3rd and 5th day. V2 stated the days of testing should have been 7/4/2024, 7/6/2024, and 7/8/2024. V2 stated that the policy shows that if contact tracing fails then broad-based approach should be used. V2 stated that means that V4 should have tested all of the residents in that area, (R2 - R56). V2 stated that the facility's policy shows that the residents should be put on transmission-based precautions. V2 stated, while looking at the facility's staff tracking form, that it was not sufficient testing. V2 stated that all staff that came in contact with V12 on 7/3/24 - 7/4/24, should have been tested on [DATE], 7/6/2024 and 7/8/2024. On 7/23/24 at 1:42 PM, V5 (Acting Administrator from 4/18/24 - 7/22/24) stated that the facility was in a COVID-19 outbreak from 7/3/24 - 7/22/24. On 7/24/24 at 3:07 PM, V5 stated that R2 - R56 should have been tested for COVID-19 immediately after V12 tested positive on 7/3/24. V5 stated while looking at the facility's COVID policy, that the policy shows to test anyone that may have been exposed to someone that is positive for COVID-19, to be tested on day 1, then again 48 hours, (if negative), and again after 48 hours for a total of 3 tests. V5 stated while looking at the facility's policy, that R2-R56 should have been put on transmission-based precautions until after 7 days from the day of exposure, and they were not. V5 stated that the staff should have been tested the same as the residents and V5 is responsible to do the testing and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145694 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 145694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renwick Nursing and Rehab 3401 Hennepin Drive Joliet, IL 60435 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 0880 tracking. Level of Harm - Minimal harm or potential for actual harm A review of V12's Attendance Application showed that V12 worked on 7/2/24 from 6:24 pm to 2:32 am. A review of the facility's 7/2/24 daily staffing sheets showed that V12 came to work at 6pm and was assigned to the same units as V11 & V14 (Nurses), and V20, V16, V19, & V2 (CNAs). Residents Affected - Some The facility was unable to provide any documentation of COVID-19 testing/tracking for any staff and for R2 R56 for 7/4/23, 7/6/24 or 7/8/24. A review of the facility's 7/10/2024 COVID-19 testing/tracking form showed testing was done or offered to only 17 of the possible 55 residents exposed, (R5 - R13 & R31 - R36). The documentation showed that they received their 1st test on 7/10/24, 6 days after being exposed. There was no documentation for the other 39 residents that were possibly exposed, (R1 - R4, R14 - R30, & R38 R56). A review of the facility's COVID-19 policy with a review date of 05/08/2024 showed the incubation period for COVID-19 is from the time of exposure until signs and symptoms appear and is estimated at 4 - 7 days but can range from 1 to 14 days. The policy shows that to establish a process to identify and manage individuals with suspected or confirmed COVID-19, post visual alerts at the entrance and in strategic places. Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others. Perform testing for all residents and healthcare professionals identified as close contacts or on the affected units if using a broad-based approach regardless of vaccination status. Testing is recommended immediately but not earlier than 24 hours after the exposure, and if negative again 48 hours after the first negative test, and if negative again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. The policy shows under Responding to a newly identified SARS-CoV-2 infected healthcare professional or resident, when performing an outbreak response to a known case, facilities should always defer to recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in a health care professional or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or broad-based approach; however, a broad based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or contact tracing fails to halt transmission. Performing testing for all residents and healthcare professionals identified as close contact or on the affected units if using a broad-based approach, regardless of vaccination status, testing is recommended immediately but not earlier than 24 hours after the exposure, and if negative again 48 hours after the first negative test, and if negative again 48 hours after the second negative test period. This will typically be at day one where day of exposure is day zero, day three, and day five. Empiric use of transmission-based precautions for residents and work restrictions for health care professionals are not generally necessary unless residents meet their criteria described in Section 2 . A review of the facility's Isolation - Categories for Transmission-based Precautions policy dated 01/20/2024 showed transmission-based precautions are the 2nd tier of basic infection control and are to be used in addition to standard precautions for residents who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Transmission based precautions will be used whenever measures more stringent than standard precautions are needed to prevent the spread of infection. A review of the state agencys Long-Term Care Facilities Guidance COVID-19 showed that testing is required for the following: Symptomatic residents or HCP (healthcare professionals), even those with mild symptoms of COVID-19, should receive a viral test for SARS-CoV-2 as soon as possible. Implement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145694 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 145694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renwick Nursing and Rehab 3401 Hennepin Drive Joliet, IL 60435 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete recommended infection prevention and control (IPC) practices when caring for a resident with suspected or confirmed SARS-CoV-2 infection. Asymptomatic residents and HCP with a close contact or higher-risk exposure with someone with SARS-CoV-2 infection are recommend to have a series of three viral tests for SARS-CoV-2 infection unless they have recovered from COVID-19 in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days . Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. The guidelines show under Outbreak testing, Facilities can choose to investigate an outbreak using contact tracing or a broad-based approach. A broad-based approach includes the unit, floor, or other specific area of the facility where the positive COVID-19 case was identified (this could be where the resident resides or where the HCP worked). If a facility is unable to conduct contact tracing or contacts cannot be identified, the facility should follow a broad-based approach. When using the broad-based approach, a facility should continue to test every 3-7 days until there are no more positive cases identified for 14 days. If additional cases are identified after testing a unit, floor, or specific area of the facility, the facility may expand testing to facility-wide testing if testing and implementation of infection control measures have failed to halt transmission. Event ID: Facility ID: 145694 If continuation sheet Page 4 of 4