Inspection·April 17, 2024

F 0686 Level of Harm - Actual harm A Lab Result note dated 2/10/24 documents a white blood cell count of 20.7 uL (4.5-11 uL), CRP of 126.2 mg/dL (normal is less than 0.3 mg/dL), and an ESR of 55 mm/hr (normal is 0-15 mm/hr). The physician was notified and ordered to send R1 to the hospital. The physician was unsure of the source of infection. R1 does have a sacral wound. Residents Affected - Few The Hospital Records dated 2/11/24 document R1 presented to the hospital for abnormal labs. R1 was sent for an evaluation of an elevated white blood cell count of 21,000. R1 denied any symptoms. The chest x-ray was negative, the blood cultures had no growth, and the urinalysis was without a urinary tract infection. R1 was reporting pain in the back. R1 was noted with a stage 4 sacral ulcer with a foul odor. The increased white blood cells are likely secondary to the sacral wound/osteomyelitis. Wound care was consulted. An Infectious Disease note from the hospital dated 2/14/24 documents R1 had an infected sacral decubitus ulcer. Plan is to continue IV antibiotics monitor the white blood cell count. A General Surgery note from the hospital dated 2/14/24 documents the sacral ulcer is a stage 4 with undermining and extends to the bone. The sacral wound measures 5 cm x 3 cm. A General Surgery note from the hospital dated 2/19/24 documents R1 underwent a debridement of the sacral wound and a bone biopsy. R1 was noted to have a necrotic wound to the sacrum with that extended down to the bone. During the debridement, the physician was able to get down to the bone layer and the bone appeared to be infected with a necrotic coccyx that was loose as well as severely eroded. The area of debridement measured 11 cm x 10 cm. After being stabilized, R1 returned to the facility on 2/24/24. A Nursing note dated 2/24/24 documents R1 returned to the facility from the hospital. Wounds were observed on the right ear, right upper back, sacrum, and both heels. Infection Charting date 3/12/24 documents R1 is receiving three different kinds of IV antibiotics for a wound infection. A Nursing note dated 3/14/24 documents the nurse practitioner ordered R1 be sent out to the hospital for evaluation. R1 had increased respiratory rate of 22 (normal is 12-16) and is now wearing 1 L of oxygen nasal cannula. The oxygen saturation are 96%. Blood pressure slightly low at 95/53. The Death Certificate dated 3/20/24 documents the cause of death as pneumonia and osteomyelitis. On 4/12/24 at 2:03PM, V3 (Wound Nurse/Floor Nurse) stated R1 admitted to the facility with an open wound to the right ear, deep tissue injury to bilateral heels, and a wound to the sacrum. V3 was not able to recall the stage of the sacral wound upon admission. V3 was also unable to recall why R1 went to the hospital on 2/10/24. V3 reported osteomyelitis is an infection that starts in the wound and enters into the bone. V3 denied being aware of R1 having any signs or symptoms of infection in the sacral wound. V3 stated signs of infection would be increased drainage, foul odor, or a change to the drainage. V3 reported the physician should be notified immediately of changes to the wound. V3 stated the best way to prevent infection in a wound is to perform the dressing changes to keep the wound clean. On 4/12/24 at 3:09PM, V6 (Nurse) stated V6 admitted R1 to the facility and R1 had wounds to the ear, sacrum, and bilateral heels. V6 was not able to remember what the stage of the sacral wound was on admission but admitted the wound was an open wound. V6 reported that when a resident is admitted the physician must be called to see what orders are going to be continued form the hospital and if any new orders will be put in place. V6 was not able to recall what was ordered for the wound on the night of admission. V6 stated if an order was not put in place on the shift a resident was admitted then it should be put in place the next shift. V6 reported the importance of an order for dressing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 - Actual harm Residents Affected - Few changes is to make sure the wound is being treated and assessed. V6 also admitted to being the nurse that sent R1 out to the hospital on 2/10/24. V6 stated R1 had an elevation of white blood cell count and the physician was concerned for an infection so R1 was sent to the hospital. V6 denied R1's sacral wound having any signs or symptoms of infection the day R1 went to the hospital. V6 reported signs and symptoms of infection are foul odor, increase in pain, and purulent drainage. V6 stated R1 was diagnosed at the hospital with a wound infection. On 4/12/24 at 3:29PM, V7 (Nurse) stated V7 was aware R1 had an infection to the wound but V7 was unaware of what kind. V7 reported signs of infection are changes in vital signs, changes in drainage of the wound, and foul odor. On 4/12/24 at 3:42PM, V2 (DON) stated R1 was admitted with bilateral heel DTIs and a sacral wound. V2 believed the sacral wound was a DTI as well because they were not able to see what was underneath the wound. V2 reported in 02/2024, R1 went out to the hospital for elevated white blood cell count and the facility was not able to identify a source of the infection. V2 denied R1 having any signs of symptoms of infection but stated the sacral wound ended up being the source of infection and was diagnosed with osteomyelitis. V2 reported once R1 returned from the hospital, R1's white blood cell count never returned to normal and remained elevated. V2 stated osteomyelitis is an infection of the bone that has migrate from another part of the body that had an infection. On 4/15/24 at 11:07AM, V9 (Wound Physician) stated R1 was admitted to the facility with the same wounds R1 was discharged from the facility with. V9 was unable to name all the wounds. V9 reported R1 was sent to the hospital in 02/2024 for elevated white blood cell count, CRP, and ESR along with a concern for osteomyelitis. V9 stated V9 was unable to remember the exact conversation but V2 reached out to V9 with concerns with the sacral wound so that prompted laboratory testing. V9 was unable to give a timeline on when a resident begins to show symptoms of osteomyelitis because every resident is different. V9 stated R1 developed necrotic tissue to the sacral wound and due to the necrotic tissue, they were unable to see if there was any infection underneath the wound. V9 denied being aware of R1 having any signs or symptoms of infection to the sacral wound. V9 reported this time of infection develops in the wound first and then moves to the bone. V9 stated if no dressing order is in place from the hospital then staff should reach out to V9 or another physician for an order. V9 denied being aware that no dressing changes were in place for one week for R1. V9 reported if dressing changes aren't being done then the wound could develop an infection due to not being clean. V9 stated zinc barrier cream is not a treatment for a wound because it will assists in keeping moisture off the skin but will not clean a wound. On 4/15/24 at 1:16PM, V2 stated the admitting nurse is responsible for getting orders from the physician once a resident is in the facility. V2 reported any care that is provided to a resident needs to have an order put into the computer system and agreed that all wound care and dressing changes requires an order. V2 stated the nurse is responsible for observing any changes to the skin and reporting them to the physician. V2 reported if a resident discharges from the hospital without any orders for wound care then the wound needs to be discussed with the physician so an order can be put in the computer. V2 stated an order for a dressing change needs to be put into place no later than 24 hours after the wound was found. V2 reported there is no reason a wound should not have any dressing change orders in place for one week. V2 stated an order needs to be put into place as soon as possible so care can be provided. V2 reported if no order was put in place then there is no way to guarantee dressing changes were being performed. V2 stated an infection can develop if the dressing changes are not done. V2 reported R1 having no order for the sacral wound should have been brought to V2's or the physician's attention sooner than one week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 - Actual harm Per the National Pressure Injury Advisory Panel (https://npiap.com/general/custom.asp?page=PressureInjuryStages) the definition of a stage 2 pressure ulcer is, partial-thickness skin loss with exposed dermis Residents Affected - Few Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). In conclusion, a stage 2 pressure ulcer is an open wound. The Wound Assessment Details Report dated 1/19/24 documents a wound to the coccyx that is a stage two that measures 4 cm x 5 cm x 0.2 cm. There are no signs of infection documented. The Wound Physician notes dated 1/23/24 documents R1 has an unstageable DTI to the sacrum that measures 8 cm x 5.1 cm x 0.1 cm. The wound is 70% granulation tissue and 30% skin. The plan is to apply calcium alginate once daily for 30 days. The Wound Assessment Details Report dated 1/25/24 documents a wound to the coccyx that is a stage two that measures 4 cm x 5 cm x 0.2 cm. This wound is considered stable at this time. It is documented that treatment in place. The Wound Assessment Details Report dated 1/30/24 documents a stage two to the coccyx that measures 8.3 cm x 6 cm x 0.1 cm. No signs of infection or documented. This wound is considered deteriorated due to an increase in size. The Wound Physician note dated 1/30/24 documents an unstageable DTI to the sacrum measures 8.3 cm x 6 cm x 0.1 cm. The wound is now 50% necrotic tissue, 30% granulation tissue, and 20% skin. The wound progress is documented as exacerbated due to nutritional compromise. The Wound Assessment Details Report dated 2/6/24 documents a wound to the coccyx that measures 10.5 cm x 7 cm by unknown. This is now classified as a stage four and was debrided on this day. The wound is considered deteriorating due to an increase in size. There are no signs of infection documented. The Wound Physician note dated 2/6/24 documents the stage four pressure wound to the sacrum measures 10.5 cm x 7.3 cm x 0.1 cm. The wound is 70% necrotic tissue, 10% granulation tissue, and 20% skin. The wound was debrided on this day to remove necrotic tissue and establish the margins of viable tissue. The wound is considered exacerbated due to generalized decline of the patient. There are no signs and symptoms of infection documented at this time. The Wound Physician note dated 2/27/24 documents the stage four to the sacrum measures 11.4 cm 9.2 cm x 3.7 cm. The necrotic tissue is 20%, the granulation tissue is 25%, and viable tissue (bone) is 55%. This wound is considered exacerbated due to the osteomyelitis with debridement in the OR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 - Actual harm Residents Affected - Few The Braden Observation 1/24/24 documents score of 17 indicating at risk for developing pressure ulcers due to being occasionally moist, chairbound, having slightly limited mobility, and a potential problem with friction and shearing. The Infection Charting dated 2/27/24 documents R1 has an infection to the sacral wound and is receiving two different kinds of IV antibiotics. The Care Plan that is not dated documents R1 has a potential for impairment to skin integrity related to impaired mobility and incontinence. R1 has a pressure ulcer on the coccyx/buttocks upon admission and bilateral DTIs on the heels that were present upon admission. An intervention documented is to treat per physician order. The policy titled, Pressure Ulcer Prevention, dated 1/15/18 documents, Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: .2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. The policy titled, admission of Residents, that is not dated documents, .Procedure: .8. Conduct head to toe nursing assessment of body systems, parts, and surfaces, identifying functional status, abilities, needs, or problems. This is to be used as baseline for the plan of care and obtaining comprehensive physician orders. 14. Moisture barrier may be applied by CNA as needed to intact skin and may be kept at the bedside. The policy titled, Skin Condition Assessment and Monitoring Pressure and Non-Pressure, dated 6/8/18 documents, Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure, injuries, and other non-pressure skin conditions and assuring interventions are implemented. Guidelines: . Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment .Caregivers are responsible for promptly notifying the charge nurse of skin breakdown .Wound Assessment/Measurement: .3 . Dressings will be checked daily for placement, clean list, and signs and symptoms of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 5 of 5