Health inspection·January 29, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review the facility failed to send an escort with a resident for an outside imaging appointment. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for transportation and escort to medical appointments, in the sample of 3. The findings include: R1 admitted to the facility with diagnoses including but not limited to chronic combined systolic and diastolic heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, ischemic cardiomyopathy, hypertensive heart disease with heart failure, nonrheumatic mitral (valve) insufficiency, COPD (chronic obstructive pulmonary disease, type 2 diabetes mellitus with foot ulcer, abnormalities of gait and mobility, unsteadiness on feet, and mild cognitive impairment of uncertain or unknown etiology, based on the diagnosis/history report. R1's elopement risk screening and evaluation dated December 13, 2024, showed a score of 8. The same elopement risk screening showed that if the score was 10 or more the resident is at risk. R1's progress notes dated January 16, 2025, at 2:05 PM, created by V4 (RN/Registered Nurse) showed, Patient out to appointment via [ride-sharing service car]. Patient to obtain X-rays with Disc and return to facility. On January 22, 2025, at 1:05 PM, V8 (Ward clerk/transportation scheduler) stated that when a resident has a scheduled outside appointment, their respective insurance company are called in advance to schedule for the transportation. According to V8, it is the insurance company who determines what type of transportation is needed by the resident based on the information regarding their mobility. V8 stated for Medicaid residents, the insurance company would ask if the resident is ambulatory and can transfer, if so, the insurance company would use a ride-sharing service car and if the resident used a wheelchair, the insurance company would use either medical-vans or regular ambulance company to transport a resident. V8 further stated that the insurance company would also ask if the resident will be traveling alone or with companion. According to V8, for R1 she called the insurance company for the resident's transportation to and from the appointment for January 16, 2025. Since R1 was ambulatory and could transfer independently, the insurance company had a ride-sharing service car used to transport R1 to his appointment on January 16, 2025. According to V8, she was asked by the insurance company if R1 was traveling alone or with companion and she said, alone. V8 stated that R1,had been sent out to his other appointments before using the ride-sharing service car without an escort and had come back without concerns. No one from nursing told me that he needed someone to go with him (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145029 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 145029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Joliet 210 North Springfield Avenue Joliet, IL 60435 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)