Health inspection·August 4, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide incontinent care in a timely manner. This applies to 1 resident (R53) reviewed for incontinent care in the sample of 29. Residents Affected - Few R53 was admitted to the facility on [DATE], per the admission face sheet. The current physician orders dated August 1, 2023, showed that R53 had diagnoses of fractured right and left femur, heart disease with failure, kidney disease, diabetes, morbid obesity, chronic lung disease, sleep apnea, depression, anxiety, myocardial infarction, constipation, overactive bladder, myocardial infarction, previous pressure on thoracic spine and neoplasm of colon and prostate. On August 1, 2023, at 9:15am foul odors were present just outside the conference room by the reception area. At 9:45am just a few doors down from the conference hall the foul odor was very strong. R8 was receiving personal care but no one was in providing care to R53 who also had a very strong odor. R53 was sleeping. On August 1, 2023, at 10:00am R53 was sleeping. At 10:50am R53 was still in the same position, no change in body position. R53 was still sleeping but wakened easily at 10:50am. R53 still had a very strong foul odor. R53 stated, They have not changed me for at least 2 hours. I've been laying here like this for a while. Yesterday they put me in a chair and did not come back for over 4 hours. I have had back surgery and it hurts my back to be in the same position that long. They don't have enough good help. It's hard for me to move myself. They have to help me. My right leg does not work to well and it hurts. On August 1, 2023, at 11:00am, V9 LPN (Licensed Practical Nurse) stated, Breakfast starts between 7:30am and 7:45am. Residents should be given incontinent care before and after breakfast. I will get R53's CNA. At 11:37am V20 CNA (Certified Nursing Assistant) stated, I take care of R53 sometimes. His CNA is busy right now. I am just helping. The disposable brief on R53 was full of dark stool. The stool was stuck to the skin on the entire buttocks, scrotum and perineal area. V20 used many disposable wipes to clean the area. The skin under the stool was pink. There were visible signs of skin opening or blistering. During turning R53 it was noted that R53 required extensive assist from 2 staff members. V20 did have help but even with another staff the bed barely could contain R53 in a side lying position because of his weakness and size. R53's current care plan only addresses urinary incontinence. There is no care plan for bowel incontinence or skin care. The current MDS (Minimum Data Set) dated, July 23, 2023, showed that R53 is not cognitively impaired. The MDS showed that R53 requires 2 staff assist with bed mobility, transfer and toileting. The MDS showed that R53 is incontinent of bowel and bladder. The MDS showed that R53 is still on the toileting program. Physician orders dated April 2, 2023, show that R53 is to be toileted every 2 hours. This order has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 2 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0677 not changed. Level of Harm - Minimal harm or potential for actual harm The facility policy for incontinence care last approved and dated June 2023 does not guide the staff to frequency of checking for incontinence or skin care. The policy does not guide staff to the cleaning of the area. Residents Affected - Few On August 1, 2023, at 1:00pm V2 DON (Director of Nursing) stated, Staff are to toilet residents after meals. The staff should be checking and or repositioning residents every 2 hours if they are incontinent. I will investigate for a new bed for R53. R53 should not be left in his chair for 4 hours unless he wants to. The staff would still have to provide incontinence care every 2 hours and reposition the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 3 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 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** 2. Residents Affected - Few On 08/02/23 at 11:20 AM V10 (Nurse) was testing R20's blood sugar levels when V10 wiped R20's 1st finger with an alcohol wipe and then collected a sample of blood. V10 did not wipe R20's finger dry or wait for the alcohol to dry before collecting the sample of blood. 3. On 08/02/23 at 11:09 AM V10 (Nurse) was testing R24's blood sugar levels when V10 wiped R24's 2nd right finger with an alcohol wipe and then collected a sample of blood. V10 did not wipe R24's finger dry or wait for the alcohol to dry before collecting the sample of blood. On 8/4/23 at 11:41am V2 (Director of Nursing) said that the finger should be wiped again after wiping it with alcohol before collecting the blood sample because it can give an inaccurate reading of the blood sugar if you don't. The facility's Accu-Chek Inform ll Glucose System policy dated 6/2022 showed under patient testing 8.B. Wipe away the first drop when testing capillary samples. This is advantageous because it ensures that the cleansing agent is dry, it stimulates blood flow and clears interstitial fluid from the sample. Based on observation, interview, and record review, the facility failed to provide, administer, or notify the nurse practitioner of an unavailable weekly medication. The facility also failed to properly obtain a blood sample for a blood glucose monitor. This applies to 3 of 3 residents (R20, R24, R435) reviewed for quality of care in a sample of 27. The findings include: 1. On 8/1/23 at 12:57 PM, R435 called her daughter to bring her Trulicity (diabetes injection medication) from her home supply. R435 said she took a weekly dose of Trulicity on Mondays and it had not been administered on 7/31/23 when it was due at the facility. R435 said her blood glucose levels had not been under control since being in the facility. On 8/3/23 at 10:40 AM, R435 said her blood glucose levels were normally better controlled at home and did not exceed above 200 mg (Milligram) per dL (Deciliter). R435 said her levels had been in the 200's to 300's since being in the facility and she was very upset about it. R435 said when she was admitted to the facility on [DATE], she told the facility staff she needed her Trulicity. R435 said on 7/31/23, she asked V19 (RN/Registered Nurse) if she was going to receive the Trulicity, and V19 said no, they did not have it. R435 said on 8/1/23, she asked V19 if they had received her Trulicity and was told they still did not have it. R435 said she told V19 she would ask her daughter to bring her home supply of Trulicity. On 8/3/23 at 12:08 PM, R435 said she self-administered her home dose of Trulicity on 8/1/23 at 1:30 PM and notified V19 she had taken her Trulicity. The face sheet shows R435 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and long term use of insulin. R435's MDS (Minimum Data Set) dated 7/31/23 shows R435 was cognitively intact. R435 was independent with eating, and walking and required supervision for bed mobility, transfers, and toileting. R435 required extensive assistance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 4 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 for personal hygiene and dressing. Level of Harm - Minimal harm or potential for actual harm On 8/3/23 at 1:28 PM, surveyor called V19 and left a voicemail requesting a call back. As of 8/4/23 at 12 PM, V19 did not return call. Residents Affected - Few On 8/3/23 at 12:33 PM, V17 (NP/Nurse Practitioner) said she had seen R435 on 7/31/23. V17 said as of 8/3/23 at 12:33 PM, she had not received a phone call from any nurse regarding R435's Trulicity not being available and not being administered. V17 said she was under the impression R435 had received her weekly dose of Trulicity. R435 said Trulicity can affect the daily blood sugars. V17 said the blood glucose levels could be elevated because R435 did not receive her Trulicity. V17 said R435 was alert, oriented, and reliable. V17 said if R435 said she did not get her Trulicity, she would believe that happened. On 8/3/23 at 12:21 PM, V4 (ADON/Assistant Director of Nursing) showed surveyor the medication fridge in the J-Hall, as well as R435's medication drawer and Trulicity was not found. On 8/3/23 at 2:53 PM, V2 (DON/Director of Nursing) said if R435 was admitted on [DATE], the Trulicity should have been available by 7/31/23 to administer. V2 said the nurse should have told the physician and the family, as well as notified V2 that the medication was unavailable for administration. V2 also said the nurse should have called the physician to notify the resident had self-administered the Trulicity. On 8/4/23 at 9:27 AM, V1 (Administrator) said the facility does not have a policy regarding what the nurse should do if a medication is unavailable. R435's progress notes were reviewed from 7/26/23 to 8/3/23, and no progress notes were written regarding R435 not receiving her Trulicity on 7/31/23, or notification of unavailability of the medication to the physician or nurse practitioner, or that R435 had self-administered Trulicity on 8/1/23. R435's July and August MAR (Medication Administration Record) were reviewed for administration of Trulicity. On 7/31/23, V19 coded in the MAR that Trulicity as unavailable for administration. R435's August MAR did not reflect R435 had self-administered Trulicity on 8/1/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 5 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, and record reviews, the facility failed to provide a safe environment for 9 residents (R2, R11, R18, R21, R20 R24, R29, R58, R18, and R176) in a sample of 29. Residents Affected - Some The findings include: 1. On 08/01/23 at 11:09 AM, R2 was in his bed and his bed was in a high position. V10 LPN (Licensed Practical Nurse) said that R2's care plan showed that he was a risk for falls, but it doesn't say that his bed needs to be in a low position. R2's 7/5/23 care plan shows R2 has paralysis and has interventions that include to educate caregivers about safety and follow facility fall protocol. On 08/01/23 at 11:45 AM, V2 DON (Director of Nursing) came to R2's room and said that R2's bed should be lower because he is a fall risk and then V2 lowered R2's bed. 2. On 08/01/23 at 12:05 PM a plastic bag with 3 4X5 inch antimicrobial dressings and a pair of scissors were found in R24's bedside table. On 8/3/23 at 12:58pm, V2 said that scissors should not be left in the resident's room. They should be left with the nurse for safety reasons. 3. On 08/01/23 at 12:50 PM a curling iron and blow dryer was found plugged into an electrical outlet in R58's bathroom. On 8/3/23 at 12:58pm V2 said that the curling iron and blow dryer should not be left plugged in because it is a safety issue. 4. On 08/02/23 at 9:15 AM, R20's was observed in her bed and her bed was in a high position when V10 LPN or came into R20's room. R20's 7/5/23 care plan showed R20 has a risk for falls with interventions including call light within reach and follow fall protocol 5. On 08/02/23 at 9:35 AM, the state surveyor and V10 entered R18's room. R18 was observed in bed with her bed in a high position. R18's care plan dated 6/30/23 shows that she has a risk for falls with interventions including to keep resident's call light within reach and follow facility fall protocol. The facility's fall risk prevent/Reduction policy dated 01/2021 showed that residents beds should be placed in the lowest positions. 6. On 8/1/23 at 11:17AM a power strip was observed in use in R29's room, next to her bed with three devices plugged into it. On 8/1/23 at 11:23AM, in hallway outside R29's room, an approximately 8 foot cord was plugged in to red outlet with the end of the cord draped over the handrail. On 8/1/23 at 11:25AM, V15 CNA (Certified Nurse Assistant) said cord in the hallway is for R29's power wheelchair. 7. On 8/1/23 at 11:17AM, R176, roommate to R29 was observed in her room where the power strip is in use. 8. On 8/1/23 at 11:19AM, R21 was observed wheeling himself down hallway past power chair cord plugged into wall and draped over handrail. 9. On 8/1/23 at 11:25AM, R11 was observed being wheeled by V15 (CNA) past power chair. The cord was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 6 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0689 plugged into wall and draped over handrail. Level of Harm - Minimal harm or potential for actual harm On 8/1/23 at 1:12PM, V2 DON (Director of Nursing) said maintenance has to approve all power strips and they need to be medical grade. V2 said the power cord for R29's power wheelchair needs to be unplugged and stored in her room. V2 said leaving the cord plugged in and draped over the handrail is a fire and electrocution risk. Residents Affected - Some On 8/1/23 at 1:27PM, V16 (Maintenance Technician), said the facility supplies two different types of power strips-one for medical supplies, and one for personal use. V16 said all power strips need to be approved by maintenance for resident safety. On 8/1/23 at 1:31PM, V16 observed the power strip in R29 and R176's room and said it was not an approved power strip. V16 said the power chair cord plugged in the hallway and draped over the handrail was unacceptable. V16 said the cord should be kept in the room because it is a trip hazard and it should not be plugged in when it is not in use, as somebody could get electrocuted. On 8/2/23 at 10:35AM, unapproved power strip was observed still in use in the room of R29 and R176. The facility's policy last revised 10/2022 titled Power Strip Usage states, Policy: .Power strips for non PCREE (Patient Care Related Electrical Equipment) in the patient care rooms .shall meet UL 1363 If power strips are used in any manner, precautions as required by the Life Safety Code and reference documents are required Procedure: .4. Patients and visitors are prohibited from using personally owned power strips. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 7 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 5. On 8/1/23 at 12:00 PM, R7 was observed in her room with CPAP and nebulizer mask on top of CPAP machine without contained in a plastic bag. Residents Affected - Some On 08/01/23 at 12:03 PM, R7 stated that she needed oxygen and used the CPAP machine at nighttime and nebulizer treatment three times daily. On 08/01/23 at 12:05 PM, V12 RN (Registered Nurse) stated, The respiratory therapist said those masks should be bagged in a plastic container. 08/01/23 01:08 PM V2 DON (Director of Nursing) stated, Oxygen masks are should be contained in a plastic bag. We don't have any specific policy on oxygen equipment storage. Based on observations and interviews, the facility failed to contain reusable nebulizer treatment, oxygen masks, oxygen nasal cannula's, and CPAP (Continuous Positive Airway Pressure) masks in a protective bag This applies to 5 residents (R7, R20, R24, R58, and R226) reviewed for respiratory care in a sample of 29. Findings include: 1. On 08/01/23 at 11:51 AM, R20's oxygen mask was observed uncovered on the chair next to her bed, her CPAP mask was observed uncovered on her bedside table, R20's respiratory flutter device was observed uncovered on her bedside table, and spirometer was observed uncovered on the bedside table. 2. On 08/01/23 at 12:05 PM R24's Oxygen tubing including nasal canula was observed on the floor uncovered. 3. On 08/01/23 at 12:50 PM R58 a nasal cannula was observed uncovered. R58 said The last time I used my oxygen was yesterday. They don't put my nasal cannula in a plastic bag like they put my CPAP mask in a plastic bag. R58's respiratory flutter device was observed uncovered on her bedside table. R58 said, The last time I used it was about a week ago. 4. 08/01/23 12:21 PM R226's oxygen tubing with nasal canula was observed uncovered and on the floor. On 8/3/23 at 12:58pm V2 DON (Director of Nursing) said all respiratory equipment including CPAP masks, oxygen masks and cannulas should be in a bag or covered when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 8 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to post the daily staffing. This effects all 87 residents in the facility. Residents Affected - Many Findings include: On 08/01/23 at 9:27am there was no posting of the facility's Daily Staffing at the reception desk. V11 (Receptionist) said that she has never seen the Daily Staffing posted since she has been working at the facility and she has never been taught how to post the staffing for the day. On 08/01/23 at 10:05am V1 Administrator said, I have been here for nine months, and we have never posted it. I know we are supposed to, but it just slipped through the cracks. On 8/3/23 at 12:58pm V2 Director of Nursing said that the facility's Daily Staffing should be posted at the front desk, and he has not seen it posted in the last nine months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 9 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0760 Ensure that residents are free from significant medication errors. 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 administer insulin as ordered and failed to notify the nurse practitioner of missed medication. Residents Affected - Few This applies to 1 of 1 resident (R435) reviewed for significant medication errors in a sample of 27. The findings include: On 8/1/23 at 12:57 PM, R435 said her blood glucose levels were not under control as they had been at home. R435 said the facility staff had not given her dose of morning insulin until an hour ago. R435 said her blood glucose level was 348 mg/dL (Milligram per Deciliter) this morning and she was not getting the correct amount of insulin to cover her carbohydrate consumption and her correction dose for elevated blood glucose levels. On 8/3/23 at 10:40 AM, R435 said she was upset about the insulin administration as it was inconsistent, and her levels were not within her normal range. The admission face sheet shows R435 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and long-term use of insulin. R435's MDS (Minimum Data Set) dated 7/31/23 shows R435 was cognitively intact. R435 was independent with eating, and walking and required supervision for bed mobility, transfers, and toileting. R435 required extensive assistance for personal hygiene and dressing. On 8/3/23 at 2:53 PM, V2 DON (Director of Nursing) said he was the nurse taking care of R435 on 7/29/23 because they were short staffed. V2 said he came in late for the shift and gave R435's 8 AM medications at 11 AM. V2 said he did not give R435 her morning dose of insulin because it was too late to administer her morning dose. On 8/3/23 at 12:33 PM, V17 NP (Nurse Practitioner) said she was not made aware R435 had missed any medications on 7/29/23. V17 said the staff should tell her if medication doses are missed. On 8/4/23 at 9:27 AM, V1 Administrator said the facility does not have a policy regarding what the nurse should do if a medication is unavailable. R435's July 2023 MAR (Medication Administration Review) documents the following: On 7/28/23 at 8 PM, the blood glucose level was 174 mg/dL. On 7/29/23 at 6 AM, no blood glucose level was documented. On 7/29/23 at 11 AM, no blood glucose level was documented. On 7/29/23 at 4 PM, no blood glucose level was documented. On 7/29/23 at 8 PM, the blood glucose level was 281 mg/dL. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 10 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0760 On 7/30/23 at 6 AM, the blood glucose level was 272 mg/dL. Level of Harm - Minimal harm or potential for actual harm On 7/30/23 at 11 AM, the blood glucose level was 326 mg/dL. All of these values are higher than the levels listed in the physicians order. Residents Affected - Few R435's progress notes were reviewed from 7/26/23 to 8/3/23. There was no documentation regarding R435 not receiving her insulin on 7/29/23 or notification to the nurse practitioner of the missed dose of insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 11 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to appropriately store medications and biologicals safely for 8 residents (R2, R13, R20, R24, R50, R55, R61, and R226) in a sample of 29. 1. On [DATE] at 11:09 AM during a tour of R50's room, R50's Nizoral medicated shampoo was observed on his bedside table, 2 tubes of Cortisone cream 2oz , 1 tube of INZO anti-fungal cream, 2 syringes with 0.9 % sodium were observed in his bedside table. R50's electronic medical record showed that his mental cognition is severely impaired. 2. On [DATE] at 11:09 AM during a tour of R2's room showed 1 tube of Zinc paste at the bedside table. R2's electronic record showed that his cognition is moderately impaired. 3. On [DATE] at 11:51 AM during a tour of R20's room showed a jar of prescription Mineral cream (was observed without a lid), 1 open bottle of 1000ml sterile water for irrigation without an open date marked on the bedside table, 1 sterile clean catch urine specimen container was observed in the bathroom, 1 8oz bottle of wound cleanser observed on a table, .5 oz tube of Therahoney, tube of antifungal ointment, 1 bottle of expired Maalox Advanced (date [DATE]) 90 count in bedside table. 4. On [DATE] at 12:00 PM during a tour of R61's room, 1 tube of Triamcinolone Acetonide Cream 0.1% 80 gram was on the bedside table, 1 16 oz. bottle Orajel antiseptic rinse for mouth sores was in thebathroom. R61's electronic medical records showed that her cognition is severely impaired. 5. On [DATE] at 12:05 PM R2's room [ROOM NUMBER] tube of Zinc Oxide paste 4oz, 1 8oz of bottle of Skintegrity wound cleaner, 3 4oz tubes of Hydragaurd silicone cream, 1 Nystatin powder 1000,000nIU /MG 60 gram bottle, 1 plastic bag with 3 opened 4X5 antimicrobial dressings, and 1 2.5 oz tube of antifungal ointment was observed in the bedside table. 6. On [DATE] at 12:21 PM, R226's room had 3 opened 10cc syringes with 0.9% sodium chloride injection and 2 unopened 10 cc syringes of 0.9% sodium chloride injection was on the bedside table. R226's electronic medical record showed that she has short-term and long-term memory problems. 7.On [DATE] at 12:34 PM R55's room had 1 1oz tube of Bacitracin Zinc ointment and 2 unopened tubes of 15cc sodium chloride tubes observed in the bedside table, 1 4oz bottle of povidone iodine 10% solution was observed in his bathroom. 8. On [DATE] at 1:07 PM, in R13's room there was a 1 8oz bottle of Skintergrity wound cleaner was observed in her bedside table. On [DATE] at 12:58pm, V2 DON (Director of Nursing) said that mineral cream RX should be kept in the nurses cart, medicated shampoo should be in nurse's cart and only admin by a nurse, antifungal, zinc, and calendula creams, wound cleaner, Therahoney, Triamcinolone Acetonide 0.1 % cream, Orajel antiseptic rinse, Nystatin powder, antimicrobial sodium chloride filled syringes, povidone iodine 10%, should not be left in the resident's rooms because it is a safety risk and the items should only be used when supervised or used by a nurse. V2 said harm could come to a resident if it is used improperly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 12 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0761 There was no physcian order in any of these residents charts to keep medications at the bedside. The electronic record showed no assessment to keep medications at the bedside. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 13 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, label, and discard food to prevent risk of foodborne illnesses. The facility failed to meet the cooked food temperature requirements to prevent the risk of foodborne illnesses. The facility also failed to fill out the temperature logs completely. This applies to 85 out 87 residents eating from the kitchen supply of food. The findings include: On 8/1/23 at 10:30 AM, freezer one had six pies left uncovered, unlabeled, and undated, a bag of chicken tenders left open to air, and an undated bag of fries left open to air. The dry good storage area had the following cans without received on dates: 3 cans of diced tomatoes, 2 cans of vanilla pudding, 5 cans of baked beans, 4 cans of banana pudding, 2 cans of pumpkin, 1 can of great northern beans, 6 cans of tapioca pudding, 6 cans of lemon pudding, 4 cans of diced pears, 7 cans of mandarin oranges, 7 cans of clam juice, 5 cans of chunk light tuna in water, and 4 cans of corn beef hashed. On 8/1/23 at 10:30 AM, the freezer in the secondary kitchen had five loaves of rye bread received on 4/27/23 with a best by date of 5/4/23. There were also five bags of hoagie sandwich rolls, each with six rolls, undated and in the freezer. On 8/1/23 at 10:30 AM, the walk-in cooler had two tubs of banana nut muffin batter. The first tub of batter was undated and when opened, had a circular, green and fuzzy matter along the top of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 14 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0812 Level of Harm - Minimal harm or potential for actual harm batter and sides of the tub. The second tub of batter showed an 'opened on' date of 6/27/23 and a 'good through' date of 7/27/23. On 8/2/23 at 11:32 AM, V21 (Cook) began taking the temperatures prior to beginning the meal service. The temperature of the baked chicken was 135 degrees. Residents Affected - Many On 8/2/23 at 1 PM, the meal trays for the F-Hall were the last to be delivered. V5 (FSD/Food Service Director) brought the open baking tray cart to the F-Hall, and after all the room trays were delivered, a test tray was requested and temperatures were taken. The tapioca pudding was at 46 degrees and the potatoes were at 117 degrees. On 8/1/23 at 10:30 AM, V5 said the food items should not be open or exposed to air, and the bags should be tied closed, covered, and dated. V5 also said the cans should have received on dates so that they know when it expires. On 8/2/23 at 1:10 PM, V5 said the tapioca pudding should be below 41 degrees and the potatoes should be above 145 degrees. V5 said if the food is not within the safe range of temperatures, it can potentially cause residents to get sick. V5 said the temperatures should be checked when the food is cooked, at food service time, and then post service. On 8/3/23 at 11:04 AM, V18 (General Manager for Dietary Services) said the pies should have been covered, and had a label showing a production date, a disposed on date, and identification of what the food item was. V18 also said if the temperature logs were blank, it means they missed taking the temperatures. V18 said chicken should be cooked to an internal temperature of 165 degrees, turkey and any sort of poultry item should be cooked to 165 degrees, eggs should be cooked to 145 degrees and above, fish should be cooked to 155 degrees, and vegetables should be cooked to 150 degrees. V18 said the temperature danger zone is from 40 to 140 degrees, and if it falls in between the hazardous zone, it can grow bacteria and get people sick. The facility's MenuWorks Daily Service Patient/Resident Taste and Temperature Logs were reviewed. The daily logs document the following: On 7/14/23 for lunch, the Dijon herb crusted fish was cooked to a temperature of 146 degrees. On 7/15/23 for breakfast, the turkey sausage was cooked to a temperature of 138 degrees. On 7/17/23 for lunch, the chicken breast was cooked to a temperature of 142 degrees. On 7/18/23 for breakfast, the temperature log was not filled out. On 7/24/23 for lunch, the temperature log was not filled out. On 7/24/23 for dinner, the sloppy joe meat was cooked to a temperature of 162 degrees. On 7/26/23 for lunch, the baked fish was cooked to a temperature of 143 degrees. On 7/27/23 for breakfast, the turkey sausage patty was cooked to a temperature of 134 degrees. On 7/27/23 for lunch, the cooked temperature was not filled out. On 7/28/23 for breakfast, the food service and post service temperatures were not filled out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 15 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0812 On 7/31/23 for breakfast, the food service and post service temperatures were not filled out. Level of Harm - Minimal harm or potential for actual harm On 8/1/23 for breakfast, the corned beef hash was cooked to a temperature of 156 degrees. Residents Affected - Many On 8/1/23 for lunch, the cooked temperatures, food service temperatures, and post service temperatures were not filled out completely. The facility's Receiving policy revised 1/2023 shows Date foods prior to placing in storage areas. The facility's Food and Supply Storage policy revised 1/2023 shows Foods past the use by, sell-by, or enjoy by date should be discarded. Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label. Use food grade plastic bags for food storage. The facility's Meal Temperature Record policy dated 1/2020 shows All food items are evaluated for proper food temperature. Take an accurate temperature of all menu items with a calibrated thermometer and recorded accordingly. If hot or cold food temperatures do not meet standards, corrective actions are implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 16 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Residents Affected - Many R281 is a [AGE] year-old male admitted on [DATE] and is under contact isolation for MRSA (Methicillin Resistant Staphylococcus Aureus) positive with Gastrostomy Tube (GT) site and buttocks wounds. On 08/01/23 at 11:50 AM, V13 (Occupational Therapist/OT) went inside R281's contact isolation room without wearing gloves and gown. V13 was inside the room for 11 minutes. V12 (Registered Nurse/RN) stated that all visitors are supposed to wear gloves and gowns to go inside the room. 08/01/23 12:01 PM V13 stated that she saw the isolation and PPE posting on the door, and she probably should have put on gloves and gown. 08/02/23 12:19 PM, two family members were in R281's room without wearing gown. On 08/01/23 at 01:08 PM, V2 (Director of Nursing/DON) stated that whoever enters the contact isolation room should wear gloves and gowns. V2 added that he would recommend his staff wear PPE even if they are talking to family for a long time (11 minutes) inside a contact isolation room. 3. R69 is a [AGE] year-old male under contact isolation due to Diarrhea and Clostridium difficile (C-Diff) positive. On 08/02/23 at 12:00 PM, in preparation for wound care, V7 (Wound Care Nurse/RN) went inside the contact isolation room (F111) and organized the bedside table by touching R69's cell phone and TV remote without wearing gloves and gown. On 08/02/23 at 12:08 PM, V7 stated, I didn't touch a patient without having gloves. But I should have worn gloves before touching his cell phone and TV remote. The facility presented the contact isolation policy revised on 06/2023 document: D. Gloves 1. Wear gloves (clean, non-sterile gloves are adequate) when entering the room, even if the patient is not in the room. E. Gown 1. In addition to wearing gloves, wear a gown (a clean, non-sterile gown is adequate) when entering the room. 4. On 08/03/23 at 09:16 AM V7 (Wound Nurse) and V6 (Certified Nurse's Assistant) was observed providing incontinence care for R20. V6 removed her dirty gloves after cleaning R20's rectal area and removing her soiled brief, then V6 applied clean gloves but did not clean her hands. V6 then put a clean brief under R20. V7 then cleaned R20's wound to her coccyx area, and then V7 clean a reddened area on R20's left leg near the buttock fold without changing her gloves and cleaning her hands. After (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 17 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 - Many V7 cleaned the second area, she removed her gloves and applied new gloves but did not clean her hands. V7 then opened R20's bedside table drawer and removed Zinc oxide cream from the drawer and applied the Zinc oxide cream to the coccyx area. V7 then removed her gloves and applied new gloves but again she did not clean her hands and she then repositioned R20 and attached R20's brief. Then V7 used R20's bed controller to lower R20's bed while wearing the dirty gloves. V7 then put the Zinc oxide cream back into R20's drawer with her dirty gloved hand. On 08/03/23 at 9:30 AM, V7 said she should have removed her gloves and cleaned her hands before applying clean gloves in-between cleaning wound areas and before applying Zinc oxide to the wound. V7 said she should have cleaned her hands between each glove change and before attaching the brief and repositioning R20. V7 said this should be done for infection control. On 08/03/23 at 9:40 AM, V6 said she should have cleaned her hands before putting on new gloves after cleaning a soiled area. V6 said this should be done to avoid cross contamination. On 8/4/23 at 12:58pm, V2 (Director of Nursing) said hands should be cleaned after removing gloves and before applying clean gloves, and during wound care gloves should be removed, hands should be cleaned, and new gloves applied before cleaning a new area. V2 said this should be done to prevent cross contamination and infection control. The facility's Dressing-Clean Technique policy dated 02/2021 showed, aseptic technique should be used. In the event of multiple wounds, each wound is considered a separate treatment. Remove gloves, perform hand hygiene, apply new gloves. The facility's Guidelines For Handwashing/Hand Hygiene policy dated 06/2022 showed, hand hygiene should be done before and after touching wounds, after touching inanimate sources that are likely to be contaminated with virulent or epidemiologically important microorganisms . and after removing gloves. Based on observation, interview, and record review, the facility failed to follow contact isolation precautions and perform hand hygiene during incontinent care and wound care. This applies to all 87 residents in the facility. Findings include: 1. R176's POS (Physician Order Sheet) shows order entered on 8/1/23 stating contact isolation until 24 hours post Natroba treatment for suspected scabies. R176's MAR (Medication Administration Record) shows Natroba was given on 8/1/23 at 4:27AM. On 8/1/23 at 11:25AM, V15 CNA (Certified Nurse Assistant) was observed entering the shared room of R176 and R29. V15 put on isolation gown and gloves before entering the room from supply bin located outside R176 and R29's room. Sign observed on R176 and R29's door showing contact precautions. V15 said R176 was diagnosed with scabies on 7/31/23 but R29, her roommate, did not have scabies. At this time, R29 was not in her room. On 8/1/23 at 11:38AM, R29 was observed propelling herself down the hallway in her power wheelchair and entered her room, shared with R176. R29 did not take any contact precautions. On 8/1/23 at 12:43PM, R29 was again, not in her room. V14 (CNA) said R29 was eating lunch on the other side of the facility with her friends from that side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 18 of 19 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 - Many Activity Note from 8/1/23 at 11:19AM shows R29 participated in nail care opportunity. Activity note says R29 was social with other residents and had her nails filed and polished. Activity Note from 8/1/23 at 4:09PM says R29 participated in Bingo activity, a social opportunity. On 8/1/23 at 1:12PM, V2 DON (Director of Nursing) said it is a problem that R29 is mobile all around the facility because she can pass scabies to other residents. On 8/3/23 at 10:32AM, V3 ADON (Assistant Director of Nursing) and Infection Preventionist said R29 was not treated for scabies. V3 said the facility has a problem with scabies and has had many cases of scabies since February 2023. V3 said R29 being mobile throughout the facility is a concern because she could expose others. V3 said both R29 and R176 should have been on isolation and all of the linens in the room should have been taken out of the room and cleaned. The facility's policy last revised 02/2021 titled, Scabies (Sarcoptes Scabiei) states, Policy: 1. Transmission: The disease is caused by Sarcoptes scabiei (a mite) which is highly contagious and spreads by close contact. Likely candidates for spread or an infestation are family members, roommates . 2. Incubation: Two to six weeks .Procedure: .3. Special Considerations: . 3. Resident should be placed on Contact isolation for 24 hours after the first treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 19 of 19