Health inspection·October 14, 2023

F 0684 New Treatment orders were received on 9/1/2023 as follows: Level of Harm - Minimal harm or potential for actual harm Left Leg- cleanse with NSS (Normal Saline Solution), part (sic) dry apply Xeroform to site, cover with ABD (abdominal) pad, kerlix every other day and PRN (as needed). Residents Affected - Few Right Leg- cleanse with NSS (Normal Saline Solution), part (sic) dry apply Xeroform to site, cover with ABD (abdominal) pad, kerlix every other day and PRN (as needed). R2's left leg wounds were assessed on 9/1/23 and 9/8/2023 by the wound care nurse. Progress Notes dated 9/7/2023 7:35 AM documents: Noted increased drainage to both lower legs. Wounds don't appear healing (sic). Wound Care Nurse notified today morning to check on wounds' status. There was no documentation in R2's electronic record that the doctor was informed of significant change observed in R2's wound. Per interview, V5, R2's Primary doctor was not informed until 9/8/23 via email by V3, Wound Care Nurse, which is not part of the resident's medical records. R2 was sent to the hospital on 9/8/2023 at 5:15 PM as ordered by Primary Doctor and was admitted with diagnosis Cellulitis of lower extremities which was more than 24 hours the significant change was observed. On 10/13/2023 at 11:41 AM, V3, Wound Care Nurse/Nursing Supervisor stated, When R2 was admitted R2 had bilateral Unna Boots on. The Unna Boots were removed on a doctor's appointment, I believe on the August 29th, 2023, I assessed her and she had pretty large venous stasis ulcers on both legs. R2 didn't come back with a discharge summary with her, so the nurse called the surgeon and the surgeon faxed over the discharge summary the same day on the 29th of August, however, it was not the correct one, it was from a previous appointment. When R2 came back from the appointment, R2 had Xeroform applied to her bilateral wounds and then I saw her again on Sept. 1st. When asked what dressings were being applied to R2's wounds on 8/30/23 and 8/31/23, V3 stated, If I remember it correctly, R2 was getting Xeroform because that is what she came back with. If dressing changes were done on 8/30/23 and 8/31/2023, it would be documented on the nurses' notes. V3 stated she didn't see any nurses' notes documenting that bilateral wound dressings of R2 were changed on 8/30/23 and 8/31/2023. V3 stated, If dressings are not changed, the wound could have an adverse effect, it could get worse, it could lose the ground that you gained. I saw R2's wounds on 9/1/23 after the Unna Boots were removed, and there were no signs/symptoms of infection, there were no odors. I measured them, the tissue was pink, she had a moderate to large amount of drainage because of how big the wounds are. R2's wounds are chronic, she has been admitted to our facility at least three times, so it's very chronic for her. But this is the first time I have seen her on Unna Boots. She's always had the pain which didn't seen greater than normal, no additional swelling, they weren't hot. On 9/7/2023, we had a care plan meeting with the R2's granddaughter and she asked me about R2's wounds and I reported to her about what I saw on 9/1/23. On 9/8/23, V6, the nurse assigned to R2 told me that the wounds had an odor, so I went and took R2's dressings off. I noticed an odor as well. I measured them and they were a little bit bigger than measurement from 9/1/23. Surveyor showed V3, her wound assessment on 9/8/23 which documents no odor. V4 stated, The wound assessment for the left leg is also wrong, the wound zone should be Anterior 26, referring to the left leg and not Posterior 29 which is referring to the back of R2 and not left leg of R2. That's an error. V3 stated, There were no treatment orders for the left and right leg vascular wounds for 8/30/23 and 8/31/23 and I did not see any documentation on the progress notes that the dressings were changed on 8/30/23 and 8/31/2023. I do wound care dressing changes on Fridays when I do my Weekly wound assessments, the rest of the days it is the floor nurses are responsible for changing the dressing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146141 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 146141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terraces at the Clare 55 East Pearson Chicago, IL 60611 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 all wounds. Level of Harm - Minimal harm or potential for actual harm On 10/13/2023 at 2:34 PM, V3, Wound Care Nurse/Nursing Supervisor stated, Since I couldn't get a hold of the surgeon, I received the treatment orders from V5, R2's Primary Doctor on 9/1/2023. From 8/29/2023 until 9/1/23, we didn't have any treatment orders for R2 until I got a hold of V5 on 9/1/23. That is not the protocol, the nurse should have called V5 on 8/29/23 and informed her that the surgeon was not calling back for orders. I didn't know that R2 came back without any treatment orders. I was only informed on 9/1/23, and that's when I called V5 to secure treatment orders. Residents Affected - Few On 10/13/2023 at 12:35 PM, V2, Director of Nursing/DON, stated Based from the information I gathered, R2 did not come back with any paper work from her appointment on 8/29/23. When the nurse called the doctor's office to follow up on the treatment orders, the doctor's clinic sent the Progress Notes from a previous appointment on 7/11/23 and not the one from 8/29/23. If dressings were applied and changed on 8/30/23 and 8/31/23, there should be documentation on the Treatment Administration Record/TAR or Progress Notes. Having a foul odor in wounds is considered a significant change in condition. If dressing changes are not done, it could lead to wound worsening. My expectation is that nurses should call the doctor if there are any significant changes. If the surgeon did not respond, the primary doctor should be called and if the primary doctor did not respond, the nurse should call the Medical Director. On 10/13/2023 at 2:20 PM, V5, R2's Primary Doctor, stated, I remember R2 well, she stayed there multiple times under my care. R2 was admitted on [DATE], when she came the order was the Unna Boot was not changed until she was seen by the vascular clinic on 8/29/23. Then on 8/29, R2 went to see the doctor. They usually tell me if there's new orders or not. She comes back and I am going to assume that nothing really changed because no one contacted me for a change. I saw her on 9/4, her legs were wrapped and there were no odors in the room, she was smiling. I got an email on 9/8 stating that the wound care doctor was going to see R2 on 9/8, the wound care nurse said, the wound is larger, and that they are putting calcium alginate. It didn't mention that there was fold odor. Now I'm thinking there must be a lot of drainage. So, I went to the electronic health record myself and I saw that the nurse on 9/7 documented on the nurses' notes, it mentions there's foul odor. So, I called facility on 9/8 spoke with V6, Registered Nurse and I told V6 that I'm concerned and I told him to send the R2 to the hospital right away. R2's blood sugars were running low so I told him to send her immediately because I was concerned about sepsis. The wound care nurse states she made multiple calls to the surgeon but nobody called her back. We have taken good care of R2 every time she is here at this facility. I understand your concern about the 2 days were there were no orders for treatment, I don't know what happened on those 2 days. I know that she had multiple debridement done when she was sent to the hospital, received antibiotics and that she was discharged back home. Hospital records were requested and was not received upon conclusion of the investigation. Facility Wound Management Policy with effective date of 2/8/2018 documents in part: PURPOSE: Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. PROCEDURE: III.B.6. Orders are verified and obtained as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146141 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 146141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terraces at the Clare 55 East Pearson Chicago, IL 60611 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 Facility Wound Significant Change Policy with effective date of 7/31/2012 documents in part: Level of Harm - Minimal harm or potential for actual harm POLICY: It is the policy of The Terraces at The [NAME] to notify the resident, his or her Attending Physician, and legal representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Residents Affected - Few PROCEDURE: 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146141 If continuation sheet Page 4 of 4