Health inspection·November 22, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 follow their abuse policy and employee handbook by having a staff member accept gifts that were purchased by a resident. This affected one of three residents (R2) reviewed for abuse. Residents Affected - Few Findings Include: R2 is a [AGE] year-old with the following diagnosis: cerebral palsy, paraplegia, epilepsy, neuromuscular dysfunction of the bladder, and bipolar disorder. The Police Report dated 10/22/24 documents R2 related that R2 is lending money to V12 (Certified Nursing Assistant/CNA) at the facility and that it was a verbal agreement. This is civil in nature. There are no other details on what gifts were given to the staff member or the amount of money. The Facility Reported Incident dated 10/22/24 documents R2 alleged that V12 misappropriated resident funds. R2 stated R2 was upset that V12 was not available to be the assigned CNA. R2 reported providing V12 with multiple gifts. V12 was educated by the administrator that no staff member can accept gifts of any sort from residents. R2 acknowledged understanding and agreed to no longer provide gifts to V12 or any staff member. R2's belongings were returned to R2. V12 denied the allegations regarding the money. V12 stated that R2 gave V12 several items as gifts. V12 explained that after R2 gave V12 the items, V12 immediately notified the manager on duty and turned all the items over to the administrator. The administrator confirmed that items were willingly turned in by V12 and given back to R2. The facility cannot substantiate our allegation of being given cash. On 11/19/24 at 11:42AM, R2 stated R2 has given V12 (CNA) $200-250 in cash over a period of three or four months. R2 reported giving V12 the money because V12 told R2 that V12 was facing financial hardships. R2 stated R2 bought V12 gifts to give to V12. R2 reported the gifts were a T-shirt, bag, and tumbler cup with the department V12 worked in. R2 stated these gifts were given to V12 sometime in October. R2 reported the cash was given to V12 with the understanding that V12 would pay R2 back but V12 has not given back any money to R2. R2 stated this is what prompted R2 to tell staff about the money because V12 was not giving any money back. R2 denied asking for it back but reported the total given to V12 kept increasing without anything being returned. R2 stated R2 gets an allowance from R2's family member that is $75 a month along with the $60 R2 receives from the facility. R2 reported V12 no longer takes care of R2 but still works in the facility. R2's mental status was assessed and R2 is alert and oriented times three. On 11/20/24 at 11:50AM, V11 (R2's Family Member) stated V11 visits about once a week and brings R2 a monthly allowance from another family member. V11 reported this allowance is brought in cash. V11 Page 1 of 3 145197 145197 11/22/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated V11 was made aware that R1 was offering money to a staff member by management. V11 reported the next visit V11 spoke with R2 above the situation and R2 admitted to giving the staff member somewhere between $200-250. V11 reported R2 has a habit of trying to buy friendship. V11 denied being aware of any gifts given to V12. On 11/20/24 at 12:52PM, V12 stated R2 is attached to V12. V12 reported one day in October R2 wanted a shower, but V12 was on a different assignment and V12 was not able to give R2 a shower that day. V12 reported R2 got upset and then went to management and reported that R2 was paying V12's bills. V12 denied taking any cash from R2. V12 stated R2 did get gifts for V12 that included a shirt, a bag, and a Tumblr cup with some writing on each of the items. V12 reported R2 did have a habit of offering cash to V12 but V12 would deny the money each time. V12 denied telling any management that R2 was offering V12 any cash. V12 stated V14 talked with V12 and told V12 that staff cannot be taking gifts from anyone. V12 denied knowing why staff cannot take gifts from residents. On 11/20/24 at 1:15PM, the surveyor interviewed R2 again to confirm what was given to V12. R2 confirmed V12 was given $200-250 in cash along with physical gifts that were bought by R2. R2 stated R2 has no way to prove the cash that was given to V12 because R2 has no receipts. On 11/20/24 at 1:28PM, V13 (Social Service Director) stated R2 came to V13 in October and reported having issues with V12 that day. R2 stated V12 didn't have time to provide a certain care task and R2 was upset. V13 reported V13 brought V12 and R2 into the office to speak with each other. V13 stated after V12 left the office, R2 told V13 that R2 was giving V12 money. V13 reported R2 is at risk for abuse due to R2's past history of being abused and a diagnosis of bipolar. V13 stated staff are not allowed to accept anything from any resident. V13 reported this is a job and staff are getting paid to provide service so no gifts or tips can be accepted. On 11/20/24 at 1:49PM, V1 (Director of Nursing/DON) stated V12 came and told V1 that R2 was upset because V12 did not get the chance to give R2 a shower. V1 went to go speak with R2 and R2 commented wishing never would have given V12 any gifts. V1 reported the gifts were a mug, a shirt, and a bag. V1 denied knowing when the gifts were given to V12 but reported V12 was instructed to bring them back to the facility. V1 denied R2 mentioning anything about cash. V1 stated V12 was suspended because V12 accepted the gifts. V1 reported V12 was educated that gifts cannot be accepted from any resident because it can be considered a form of abuse. V1 stated this would be considered misappropriation of property. On 11/22/24 at 11:27AM, V14 (Administrator) stated V14 was told by V12 and V1 that R2 had been giving gifts to V12. V14 reported the gifts were a bag, a water bottle, and a shirt. V14 stated R2 told V14 that R2 was giving cash to V12. V14 stated V12 denied receiving cash. V14 reported the allegation of gifting cash could not be proved without any receipts. V14 stated R2 is at risk for abuse due to this behavior of gift giving. The Care Plan dated 3/1/24 documents R2 is an adult with chronic health conditions and comorbidities that require support to maintain stability in the highest practicable level of functioning. It is recognized that living with such conditions and requiring long-term care maybe viewed as a form of trauma, R2 maintains not having been the perpetrator and/or recipient of mistreatment, abuse, neglect, and/or exploitation. Intervention includes to ensure that R2 is in a safe and secure environment with caring professionals. The Care Plan dated 3/17/24 documents R2 has a mood problem related to bipolar disorder at times 145197 Page 2 of 3 145197 11/22/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and can be attention seeking. R2 has been proven to make false allegations in regards to finances and gifting of gifts and money. The Abuse/Neglect Screening dated 9/3/24 documents a score of four indicating R2 is at moderate risk for abuse due to psychiatric history, diagnosis of depression, history of abuse and/or neglect, and factors that increase R2's vulnerability. A Social Service note dated 10/29/24 documents social services met with R2 to have a conversation about childhood and family. R2 did express that R2 thrives off attention as it was something lacking in our childhood. A discussion was had about self-love, acceptance, and building friendships. R2 emphasized that R2 does not know how to build healthy friendships. V12's employee file was reviewed. A Notice of Corrective Action dated 11/1/24 documents V12 was suspended for undocumented number of days. V12 failed to adhere to the facility policy by accepting gifts, money, and food from R2 in exchange for services. V12 will be educated on appropriation of resident funds and property as well as. V12 will also receive an abuse in-service and was presented a final warning. Progressive discipline will lead to termination if necessary. The Employee Handbook was reviewed. On page 30-32, it is documented the facility expects that each employee's conduct and performance will conform with the highest standards of professionalism and ethical practice; the requirements of their job; published and common-sense health and safety rules; and applicable, federal, state and local laws, rules and regulations. Violations of conduct standards that constitute grounds for immediate dismissal include asking a resident for money or gifts or approaching a resident within intention of soliciting money or other gifts; soliciting or accepting gifts, tips or contributions from suppliers, residents, family members or visitors, unless specifically authorized in writing by the compliance officer. On page 34, it documents all employees have an ethical and professional responsibility to support and promote the highest standards of conduct. The facility has a zero-tolerance policy for abuse and neglect. The abuse, neglect, or other mistreatment or residents in the facility is unlawful and prohibited. The Resident Rights policy is attached in the employee handbook which is reviewed by each employee upon hire. The policy includes that the residents have certain fundamental rights guaranteed by law, including, but not limited to, the following: . to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. On page 85 of the employee handbook, it documents staff may find that there are times a resident, family members or vendors want to show appreciation to staff by giving gifts. It is strictly prohibited to accept any gifts from any resident, family member, or vendor. If a resident or family member is insistent, please refer them to the administrator or supervisor. The New Employee General orientation was completed for V12 on 11/3/2023. Topics include: code of conduct, abuse and/or neglect, and resident rights. The policy titled, Abuse Prevention and reporting - Illinois, dated 10/24/22 documents, This facility for the right of our residents to be free from abuse, neglect, exploitation, appropriation property, deprivation of goods and services by staff or treatment. This facility, therefore prohibits abuse, neglect, exploitation, misappropriation of property, and treatment of residents . Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident belongings or money without the resident's consent. 145197 Page 3 of 3