Health inspection·May 2, 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 provide skin assessments for skin injuries. This applies to 3 of 4 residents (R1, R3 and R4) reviewed for skin conditions. Residents Affected - Few Findings include: 1. R1 admitted to the facility on [DATE] and discharged from the facility on 4/22/24. R1 has diagnoses that includes cellulitis, chronic obstructive pulmonary disease, chronic gout, malignant neoplasm of prostate, type 2 diabetes, obstructive sleep apnea, chronic kidney disease, hypertension and atherosclerotic heart disease of native coronary artery. Care plan dated 4/17/24 has Risk for impaired skin integrity. Interventions includes evaluate skin for blanching, redness, excoriation and skin integrity. Provide skin care per facility guidelines and as needed. The MDS (Minimum Data Set) dated 4/22/24 shows R1 is cognitively intact. R1 required partial staff assistance with toilet transfers. R1 was assessed to be always continent of bowel and bladder. R1's hospital discharge paperwork includes an infectious disease progress note dated 4/16/24. Note states bilateral feet with diffuse skin scaling, bilateral feet with edema left greater than right but no longer TTP (Thrombotic Thrombocytopenic Purpura) in the feet or ankles. No rash skin is dry. Right calf wound dressed clean dry and intact. No nursing skin observation of wounds were documented until 4/19/24 by V3 Wound Nurse. The chronic traumatic right medial calf wound measured area of 6.57 cm2, length 4.19cm, width 2.32 cm, depth 0.1cm. The left dorsum foot measured area of 0.17cm2, length 0.45 cm, width 0.47cm and depth of 0.1 cm. Facility CNA (Certified Nursing Assistant) documentation of skin observations from 4/18/24 thru 4/21/24 documents no scratches, red area, discoloration, tear or open area. On 4/26/24 at 2:54 PM V11 (Family Member) stated every time she came to the facility V11 stated wounds on R1's feet developed in the facility and was soiled with urine. On 5/1/24 at 11:39 AM, V3 (Wound Nurse) stated she saw R1 and assessed his wounds on 4/19/24. V3 stated the admitting nurse should have done a skin and wound assessment on admission 4/17/24. 2. R3 was admitted to the facility on [DATE]. R3 has diagnoses that includes type 2 diabetes, chronic obstructive pulmonary disease, chronic kidney disease, functional quadriplegia, cerebral atherosclerosis and history of transient ischemic attack. R3's physician orders include a head-to-toe evaluation every day shift on the 27th. None was provided by the facility. The care plan dated 3/39/24 includes an ADL self-care performance deficit related to functional quadriplegia, dementia and cerebral atherosclerosis. C.N.A documentation not skin redness. No nursing skin assessment documentation was available for review for R3. On 4/30/24 at 11:54 R3 stated she had a sore on her buttocks. R3 stated staff do not check her every two hours. On 4/30/24 at 12:06 PM V4 CNA was observed performing incontinence care for R3. Surveyor noted a pea sized open area on the skin to R3's left inner buttock. On 4/30/24 at 4:15 PM, V4 CNA stated she had cleaned R3 up but had not seen the open area before it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 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 was pointed out by surveyor. Level of Harm - Minimal harm or potential for actual harm 3. R4 was admitted to the facility on [DATE]. R4's diagnoses include cerebral atherosclerosis, Alzheimer's disease, congestive heart failure age related osteoporosis, and osteoarthritis. R4's physician orders include admit to hospice care, head to toe assessment monthly on the 19th, turn and reposition every 1.5 to 2 hours. R4's care plan dated 3/1/24 states R4 has a self-care performance deficit related to Alzheimer's and cerebral atherosclerosis. Resident requires extensive assistance by staff to turn and reposition in bed. R4's MDS dated [DATE] show cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 6. Residents Affected - Few On 4/30/24 at 12:35 PM, V6 (Family Member) stated she comes to visit R4 3 to 4 times per week and stays 3 to 4 hours. V6 stated there have been visits she has had to ask staff to turn and clean R4 because they had not done it after 3 hours. V6 stated she and the hospice nurse are the ones who have notified facility staff of skin issues. On 4/30/24 at 12:59 PM V7 RN (Hospice Registered Nurse) stated R4 is [AGE] years old and very thin, but she could not say her skin wounds and irritation were [NAME] wounds. V7 stated not being moved for 3 to 4 hours will cause skin break down. V7 provided incontinence care to R4. R4 had a border foam dressing in place on coccyx dated 4/26. V7 removed the dressing. R4's buttocks and sacrum were reddened. R4 had blanchable redness to her right hip. On 4/30/24 at 5:27 PM, V9 LPN (Licensed Practical Nurse) stated V7 Hospice RN informed her R4 had skin redness. V9 stated she has seen border foam dressings in place for as long a 5 to 7 days when used for protection. V9 stated skin assessments are done weekly by the nurse on shower days. CNAs / shower aids do skin assessment twice per week during the shower or bed bath. On 4/30/24 at 4:31 PM, V3 (Wound Nurse) stated the coccyx wound for R4 had healed and she signed off on 4/24/24. If something new develops she depends on staff to alert her. CNAs and Nursing staff should be doing skin checks during cares, bed baths and showers. V3 stated R4 should have had a skin assessment since she saw her on 4/24/24. V3 stated if someone is left in urine and stool for extended periods time or not turned every two hours, they can develop skin break down. Peri care should be provided every two hours or sooner if necessary. On 5/1/24 at 10:35 AM, V10 LPN (Licensed Practical Nurse) stated Nurses don't do skin checks, on shower days the CNA's do the skin checks. If there is a skin concern the CNA's let the nurse know. Nurses do the quarterly skin assessments. On 5/1/24 at 2:43 PM, V2 ADON (Assistant Director of Nursing). V2 stated nurses should do a skin assessment on admission and shower days. The CNA should document on the shower sheet and notify the nurse of any new issues. The nurse is responsible to notify the Nurse Practitioner or Physician of any issues. V2 stated the facility nursing staff is still doing skin assessments for resident receiving hospice services. On 5/1/24 at 3:16 PM, V1 (Administrator) stated staff should be turning and checking residents every two hours. V1 stated there have been a lot of complaints from residents stating they aren't being assisted every two hours the longest was four hours. V1 stated the admissions nurse do a head-to-toe assessment and document any wounds on admission. If there is a wound the wound nurse should be notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 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 Level of Harm - Minimal harm or potential for actual harm The facility policy General Requirements for Nursing and Personal Care [NAME] date 6/2023 states .an evaluation of each resident shall be conducted upon admittance and as necessary to determine the susceptibility of the resident to skin breakdown. Preventative measures and treatment shall be carried out by the facility staff . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 4 of 4