Health inspection·May 29, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R3's skin impairment care plan dated May 20, 2025, showed [R3] has a fractured right leg, skin tears to the bilateral forearms, a deep tissue injury to the left heel and remains at risk for further skin integrity issues related to reduced mobility, aging fragile skin, Braden score of 14. The care plan continued to show multiple interventions dated May 20, 2025, including Follow facility protocols for treatment of injury. On May 29, 2025, at 1:36 PM, V6 (Wound Care Nurse) said R3 was admitted to the facility on [DATE], with a left heel DTI (Deep Tissue Injury). V6 said the wound care doctor was not following R3's wound because the wound was small and stable. V6 said she does not document wound assessments in the EMR. On May 29, 2025, at 11:18 AM, V2 said R3 did not have a complete admission wound assessment or weekly wound assessments. V2 said V6 should have completed and documented these assessments. The facility does not have documentation to show R3's left heel DTI had a complete assessment conducted including measurements of R3's left heel DTI and description of the pressure ulcer on admission to the facility and weekly. 3. R2's EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including urinary tract infection, muscle wasting and atrophy, and dementia. R2's pressure ulcer care plan dated March 4, 2025, showed [R2] has stage 4 pressure injury to the sacrum and remains at risk for further skin breakdown related to bowel incontinence, poor mobility, aging fragile skin, Braden scale of 13, diagnosis of muscle wasting. The care plan continued to show multiple interventions dated March 4, 2025, including Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to physician. On May 28, 2025, at 1:40 PM, V6 said on February 20, 2025, R2 developed a sacral pressure ulcer. On May 29, 2025, at 11:18 AM, V2 said R3 did not have a complete wound assessment for the week of May 15, 2025. V2 said V6 should have documented a complete assessment. The EMR showed R2 was not seen by the wound doctor on May 15, 2025, due to R2 being out of the facility on an appointment. The facility does not have documentation to show R2's weekly pressure ulcer assessment was completed to show description of R2's pressure ulcer and measurements of the pressure ulcer. The facility's policy titled Documentation of Wound Treatments dated December 2024, showed Policy: The purpose of this policy is to provide a consistent, complete, and accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Policy Explanation and Compliance Guidelines: 1. The community [NAME] maintain clinical records on each resident receiving wound treatments in accordance with accepted professional standards and practices that are: a. Complete; b. Accurate; c. Readily Accessible; d. Systemically organized . 3. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. 4. The following components are documented as part of a complete wound assessment: a. Type of wound (pressure injury, surgical, etc.) and anatomical location; b. Stage of the wound, if pressure injury (stage I, II, III, IV, deep tissue injury, unstageable) or if non-pressure, the degree of skin loss (partial or full thickness); c. Measurements: height, width, depth, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 If continuation sheet Page 2 of 3 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 - Minimal harm or potential for actual harm undermining, tunneling; d. Description of wound characteristics: i. Color of the wound bed; ii. Type of tissue in the wound bed (i.e. granulation, [NAME], eschar, epithelium); iii. Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated); iv. Presence, amount, and characteristics of wound drainage/exudate; v. Presence or absence of odor; vi. Presence or absence of pain . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 If continuation sheet Page 3 of 3