Inspection·February 28, 2024

F 0684 The findings include: Level of Harm - Minimal harm or potential for actual harm 1. On February 26, 2024, at 12:02 PM, R38 was sitting up in the dining room. She had a surgical boot on her left foot. Her left foot was wrapped with a gauze dressing. Residents Affected - Few On February 27, 2024, at 10:27 AM, R38 was sitting up in the dining room. She was wearing a surgical boot on her left foot. Her left foot was wrapped with a gauze dressing. On February 27, 2024, at 2:01 PM, R38 was lying in bed. V3 Registered Nurse (RN) was changing R38's dressing to her left foot. R38's left foot was very dry and had a tint of yellow. Her 2nd toe was missing. There were sutures in place of the toe. V3 RN stated, she has had the sutures since she came back from the hospital. She wasn't sure why R38 still had sutures in. Medical Records make the follow up appointments. R38's discharge hospital paperwork shows, she was discharged from the hospital on January 16, 2024, with diagnoses of cellulitis of foot, toe abrasion and osteomyelitis. She was to follow up with her primary care physician in 1 week. R38's progress notes dated January 16, 2024, shows, Resident returned to facility from local hospital where had 2nd left toe amputated due to osteomyelitis. Dressing to the left foot intact, needs to be checked every other day, betadine solution to apply . R38's medical records does not show that resident has any surgical wound or sutures. There are no assessments on her left foot on admission or up to the date of the survey. R38's February 2024 TAR (treatment administration record) shows, Apply betadine to (L) (left) foot over with dry gauze & lightly wrap with kerlix (gauze dressing) every other day & PRN (when needed) one time a day every other day for 30 days. The order was completed on February 14, 2024. R38's Nurse Practitioner progress notes dated February 9, 2024, shows, Assessment/Plan: .S/P (status post) left 2nd toe amputation 2/2 to osteomyelitis (1/9/24 (January 9, 2024)): .F/U (follow up) with podiatrist, NOD (nurse on duty) with f/u with scheduler. On February 28, 2024, at 12:28 PM, V12 Nurse Practitioner stated, she didn't know that R38 had sutures to her left foot because it was always wrapped with the gauze dressing. None of the nurses made her aware of the sutures. She stated, she told the nursing staff to make sure to have R38 follow up with the podiatrist who did the surgery. She also added that the sutures should have been removed. The safest amount of time to leave the sutures in would be 21 days. (It has been 50 days since R38's amputation of her 2nd toe). On February 28, 2024, at 9:56 AM, V4 Medical Records stated, she made an appointment with the podiatrist two weeks ago to follow up from R38's amputation on January 9, 2024. She also stated, the nurses do not do any of the follow ups, only her. They may have told her and she forgot. She couldn't remember. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 2 of 9 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R62's Wound Evaluation Management Summary dated 1/26/24 show R62 has stage 4 pressure wound to his sacrum. Residents Affected - Few R62's Physician Order Sheet treatment dated 2/24 show an order of -Cleanse sacral wound with normal saline then apply silver calcium alginate dressing and cover with border gauze dressing one time a day. Start Date 2/6/2024. On 2/26/24 at 10:30 AM, R62 was in bed with low air loss mattress. R62 was alert and pleasant. R62 said she has a wound on her bottom. At 11:15 AM, V9 (Certified Nursing Assistant-CNA) was in R62's room and provided incontinence care. R62 had no dressing in place to the wound on her sacral area. V9 (CNA) said she also provided incontinence care to R62 this morning at around, at 7:00 AM. R62 did not have a dressing to her wound. V9 said she did not tell R62's nurse this morning as she was busy. V3 (Registered Nurse- RN) came in R62's room and said R62 should have a dressing to her wound at all times. V3 (RN) said she will tell the Wound Nurse. On 2/27/24 at 10:00 AM, V5 (Wound Nurse) said R62 has a Stage 4 open area to her sacral area that is healing. Staff should continue to perform R62's wound dressing as ordered for the wound to continue to heal. R62's latest wound assessment dated [DATE] shows: Wound Size: 0.7 centimeters (cm) x 0.5 x 0.2 cm, stage 4. On 2/26/24 at 1:00 PM, V8 (Wound Physician) was at the facility to see R62. V8 said these dressings are not simply Band-Aid but they are therapeutic dressing to heal the wound and protect the wound from incontinence and from infection. Based on observation, interview and record review the facility failed to identify pressure injuries prior to an unstageable necrotic wound and failed to assess a pressure injury when identified. The facility also failed to ensure pressure reliving interventions and treatments were in place. This applies to 2 of 7 residents (R72 & R62) reviewed for pressure injuries in the sample of 18. The findings include: 1. R72's face sheet shows she is a [AGE] year-old woman with diagnoses to include: diabetes mellitus type two, dementia, pressure ulcer of left heel, stage 4, non-pressure chronic ulcer of left ankle with fat layer exposed, and adult failure to thrive. On February 26, 2024, at 9:58 AM, R72 was asleep in bed. The head of the bed was elevated to an approximate 45-degree angle. She was turned on her left hip. At 11:17 AM, 12:17 PM and 1:50 PM, R72 was lying in the same position she was in at 9:58 AM. On February 27, 2024, at 12:31 PM, V3 Registered Nurse (RN) was changing R72's wound on her left heel. R72's left leg was contracted. Her left leg was bent at the knee where her left foot was resting on her right buttock and the outside of her left ankle was resting on the bed. There was one pillow under her right thigh. The pillow was not reliving any of the pressure on her contracted left leg. There was also a wedge resting on the right side of her but was not turning her on her left side. R72 had an approximate half dollar size open wound to her left inner heel where it was resting on her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 3 of 9 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 Residents Affected - Few right buttock. R72 had another approximately half dollar size wound on her left mallelous (bone on her outer ankle) where it was resting on the bed. R72 did not move herself and needed to be assisted with turning. When V3 RN was done changing R72's dressings she applied the pillow in the same spot. Neither wound was offloaded and was resting on her right buttock and the bed. On February 27, 2024, at 1:00 PM, V5 Wound Care Nurse (WCN) stated, R72's wounds were because her left leg was contracted and underneath her right leg. She can only move her right leg. The staff should be using a wedge to lift her right leg off of her left heel, so the heel isn't resting on her right buttock. They should also be using a pillow under her left foot to keep her outer ankle off the bed. The wound doctor wanted to try this intervention to see if it improved the wounds. If that did not help, then they would try something else. That was awhile ago. She stated, R72's inner heel wound was found at an unstageable necrotic (dead tissue) wound. R72's progress notes dated July 1, 2023, by V5 WCN shows, During changing of resident, CNA (certified nursing assistant) noted with redness on right buttocks that is non-blanchable and pressure sore on left heel . Resident will be put down to see wound the doctor. There is no assessment/skin & wound evaluation of R72's pressure sore on left heel until July 10, 2023. (9 days later) R72's skin & wound evaluation dated July 10, 2023, shows, an unstageable pressure ulcer to the left heel. The wound had 100% of wound filled with eschar (dead tissue), measuring 2.9 cm (centimeters) X 1.9 cm (length X width). R72's wound doctor wound evaluation & management summary dated July 10, 2023, shows, Chief Complaint: Patient has wounds on her right buttock; left heel. The evaluation shows an unstageable (due to necrosis) of left heel, full thickness. The wound is pressure measuring (length x width x depth) 3.5 X 3.5 X not measurable cm, depth is unmeasurable due to presence of nonviable tissue and necrosis. The same assessment shows, resident has a severe contracture that keeps the heel under the buttock. She is active and moving all the time, at the time of the assessment. Heel boots were impossible as they were kicked off within minutes. Will continue to try to find methods of offloading. R72's care plan or medical record does not show she doesn't keep her heel boots on or that other interventions were tried to prevent a necrotic pressure ulcer to her heel. R72's Minimum Data Set, dated [DATE] (prior to wound development) shows, she is not cognitively intact and requires 2 or more staff members to assist with bed mobility. R72's care plan date-initiated March 15, 2023, shows, Focus: R72 has impairment to skin integrity r/t (related too): contracture, stage 4 pressure ulcer to left heel and non-pressure wound to left lateral ankle. Interventions/Tasks: Follow facility protocols for treatment of injury, monitor skin for irritation/breakdown, notify MD (medical doctor) PRN (when needed). R72's care plan date-initiated February 3, 2023 shows, The resident has limited physical mobility r/t weakness and contractures which requires the use of the [mechanical lift] transfer device. Resident is unable to bear weigh to the lower extremities . The facility's pressure ulcer prevention and treatment interventions policy dated April 2020 shows, Guideline: To provide guidance for pressure ulcer prevention and treatment interventions. A. Daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 4 of 9 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 skin hygiene and inspection.4. Inspect skin daily with care for signs and symptoms of breakdown . B. Decreased mobility, activity or sensory perception .2. Establish a turning and repositioning schedule if the resident is immobile . 5. Boney prominences susceptible to pressure will be protected . 10. Avoid positioning the resident on a pressure ulcer . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 5 of 9 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 - Potential for minimal harm Based on observation, interview, and record review the facility failed to post their nurse staffing information. This has the potential to affect all 79 residents residing in the facility. Residents Affected - Many The findings include: On 2/28/24 at 10:55 AM, the nurse staffing information was not posted. On 2/28/24 at 10:58 AM, V10 Receptionist said she didn't have any staffing numbers posted, just the schedule of who is working. V10 said she directs staff to their assignment when they come in for the day. On 2/28/24 at 11:51 AM, V2 Director of Nursing (DON) said staffing information was not posted. V2 said the staffing information should be posted. V2 said it is normally posted near the entryway of the facility. The CMS 671 dated 2/26/2024 shows a resident census for 79. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 6 of 9 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow recipes to ensure nutritional value and palatability was retained for 9 residents of 9 residents (R21, R8, R7, R1, R19, R383, R38, R75, and R45) reviewed for pureed diets in the sample of 18. Residents Affected - Some The findings include: On 2/26/24 at 11:16 AM, V11, Dietary Manager/Cook used water to thin the broccoli casserole for the pureed chicken broccoli casserole. On 2/26/24 at 12:30 PM, surveyors obtained a sample tray for the pureed lunch meal, sampled the pureed chicken broccoli casserole, and found it to be bland, lacking flavor, and watery tasting. On 2/27/24 at 2:02 PM, V11 said it is important to follow the recipe to maintain nutritional values. V11 said water or milk can be used to thin pureed foods, the recipe does not show which to use. The facility's F/W 23/24 Menu for Week 3 shows the lunch meal for Monday includes Chicken Broccoli Casserole. The facility's Pureed Chicken Broccoli Casserole recipe provided by the facility for F/W 23/24-Week 3 Monday Lunch shows, May add hot broth and/or thickener, as needed, to achieve desired consistency. The facility's Diet Type Report dated 2/28/24 shows R7, R21, R8, R1, R19, R383, R38, R75, and R45 are on a pureed diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 7 of 9 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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. Based on interview and record review the facility failed to test and record the concentration level of the sanitizer in the low temperature dishwasher at breakfast, lunch, and supper. This failure has the potential to affect all 79 residents residing in the facility. The findings include: During the initial tour of the kitchen on 2/26/24, V11, Dietary Manager, said the sanitization level of the dishwasher should be checked three times a day before each meal. The instructions on the Dish Machine Log-Low Temp provided by the facility for the month of February (2024) shows the sanitizer concentration should be recorded three times a day; breakfast, lunch, and supper. The same log does not have a sanitization concentration level recorded at lunch or supper on 2/25/24 or breakfast on 2/26/24. The CMS 671 form dated 2/26/24 shows there are currently 79 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 8 of 9 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 ensure all residents were offered and/or received the recommended pneumococcal immunizations to 1 of 5 residents (R72) reviewed for immunizations in the sample of 18. Residents Affected - Few The findings include: R72's admission Record dated 2/28/24 shows R72 is a [AGE] year-old female admitted to the facility on [DATE]. R72's diagnoses include, but are not limited to, diabetes mellitus, type 2, dementia, adult failure to thrive, hypertensive heart disease, and anemia. R72's Immunization Report dated 2/27/24 does not show any documentation of R72 having received or been offered a Pneumococcal vaccine. On 2/29/24 at 9:15 AM, V5, Infection Prevention Nurse, said they offer residents a pneumococcal vaccine on admission. The facility was unable to provide documentation showing R72 was offered, received, and/or refused a pneumococcal vaccine. Per current Centers for Disease (CDC) guidelines, R72 was eligible and recommended for a Pneumococcal Vaccine (PCV15 or PCV20). The facility's Flu/Pneumovax Vaccine Policy (effective 10/2020) shows Pneumococcal vaccination should be offered to residents at the time of admission. Resident refusal of vaccines should be documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 9 of 9