Health inspection·March 31, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who were dependent on staff for care were provided with showers according to the facility protocol and residents' preference. This failure applied to eight (R1, R2, R3, R4, R6, R7, R9, and R12) of twelve reviewed for showers during the month of March 2025. Residents Affected - Some Findings include: 1. R1 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses that include and are not limited to hemiplegia and hemiparesis, hypertension, and chronic diastolic heart failure. Per the Minimum Data Set (MDS) dated [DATE], R1 needs substantial/maximal assistance, helper does more than half the effort during shower activity. On 3/29/2025 at 10:00 am R1 wrote in a notebook, I am very unhappy because I do not receive the showers on Wednesday's, Saturday's or when I request them, I do not like to be dirty and smelly. On 3/30/2025 at 10:00 am, V2 (Director of Nursing/DON) said R1 shower schedule days are Wednesday and Saturday on 3-11 shift; per our documentation, R1 only received a shower on 3/5/2025. The other days, I do not see any documentation if the shower was given or not on the following days: 3/8, 3/12, 3/15, 3/19,3/22, 3/26, and 3/29/2025. I cannot find any documentation on those days. 2. R2 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses that include and are not limited to: hemiplegia and hemiparesis, epilepsy, and hypertensive heart disease. Per the Minimum Data Set (MDS) dated [DATE], R2 is dependent on two or more helpers for shower activity. On 3/29/2025 at 10:25 am R2 said I do not like to be filthy and with a body odor. I am used to taking a shower daily, but I am not getting that. I do not like to feel dirty. I cannot do it by myself, I need the staff to help me with my showers. On 3/30/2025 at 10:35 am, V2 (DON) said, R2 shower schedule days are Monday and Thursday during 11-7 shift. Per our documentation, R2 received a shower only on 3/10/2025. I cannot find any documentation on the other days: 3/3, 3/6, 3/13,3/17, 3/20, 3/24, and 3/27/2025. I do not know if R2 received the shower or not. I cannot find any documentation on those days. 3. R3 is a [AGE] year-old male originally admitted on [DATE] with medical diagnoses that include and are not limited to: Streptococcal arthritis left knee, diabetes, and difficulty in walking. Per the Minimum Data Set (MDS) dated [DATE], R3 needs substantial/maximal assistance, the helper does more than half the effort during shower activity. Page 1 of 3 145197 145197 03/31/2025 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/29/2025 at 10:40 am, R3 said, I am here for almost a month, and I have not received any showers. I am working very hard in therapy because I want to go home and ask my family to help me take a warm, never-ending shower. On 3/30/2025 at 10:45 am V2 (DON) said R3's shower schedule is on Tuesday and Friday 7-3 shift. I cannot find any days in our electronic medical record that R3 had received any showers. R3 was supposed to be showered on 3/4, 3/7, 3/11,3/14, 3/18, 3/21, 3/25 and 3/28/2025. I cannot find any documentation on those days. 4. R4 is a [AGE] year-old male originally admitted on [DATE] with medical diagnoses that include and are not limited to: Chronic obstructive pulmonary disease, diabetes, and anxiety disorder. Per the Minimum Data Set (MDS) dated [DATE], R4 needs partial/moderate assistance during showers, the helper provides verbal cues and contact guard assistance to complete the shower activity. On 3/29/2025 at 11:00 am R4 said, I need to take a shower, I do not go to the shower room because the floor is too slippery, and I am afraid of having a fall. I want to take a shower every day. On 3/30/2025 at 10:20 am, V2 (DON) said R4 has scheduled shower days on Monday and Thursday during 7-3 shift. Per our electronic medical record, R4 received showers on 3/3, 3/17, and 3/20/2025. R4 was supposed to be showered on 3/10, 3/13, 3/14, and 3/27/2025. I cannot find any documentation on those days. 5. R6 is an [AGE] year-old female originally admitted on [DATE] with medical diagnoses that include and are not limited to hypothyroidism, hypertension, and morbid obesity. Per the Minimum Data Set (MDS) dated [DATE], R6 is dependent on two or more helpers for shower activity. On 3/29/2025 at 12:00 pm, R6 said, I do not want to come out of the room because I had not taken a shower, and I do not want people to tell me I have a bad body odor. On 3/30/2025 at 10:12 am, V2 (DON) said R6's scheduled shower days are Tuesdays and Fridays during the 3-11 shift. Per our electronic medical record, R6 received a shower on 3/4, 3/11, 3/14, 3/18, 3/21, and 3/25. R6 was supposed to be showered on 3/7/2025. I cannot find any documentation on that day. 6. R7 is a [AGE] year-old female originally admitted on [DATE] with medical diagnosis that include and are not limited to: multiple sclerosis, chronic pulmonary disease ad hypertension. Per the Minimum Data Set (MDS) dated [DATE], R7 needs substantial/maximal assistance, the helper does more than half the effort during shower activity. On 3/29/2025 at 12:35 pm R7 said, I do not get the showers as per the schedule. On 3/30/2025 at 11:15 am, V2 (DON) said R7's scheduled shower days are Mondays and Thursdays during the 11-7 shift. Per our electronic medical record, R7 received a shower only on 3/13/2025. R7 was supposed to be showered on 3/3, 3/6, 3/10, 3/17, 3/20, 3/24, and 3/27/2025. I cannot find any documentation on those days 7. R9 is a [AGE] year-old male originally admitted on [DATE] with medical diagnoses that include and are not limited to: morbid obesity, Guillain-Barre Syndrome, and seizures. Per the Minimum Data Set (MDS) dated [DATE], R9 needs substantial/maximal assistance, the helper does more than half the 145197 Page 2 of 3 145197 03/31/2025 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0677 effort during shower activity. Level of Harm - Minimal harm or potential for actual harm On 3/29/2025 at 1:00pm, R9 said I do not get showers. I would like to take a shower to feel clean and not have oily hair and skin. Residents Affected - Some On 3/30/2025 at 10:30 am V2 (DON) said R9's scheduled shower days are Wednesdays and Saturdays during 3-11 shift. Per our electronic medical record, R9 received a shower only on 3/5/2025. R9 was supposed to be showered on 3/8. 3/12, 3/15, 3/19, 3/22, 3/26 and 3/29/2025. I cannot find any documentation on those days. 8. R12 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses that include and are not limited to diabetes, Alzheimer's Disease, and spinal stenosis of the cervical region. Per the Minimum Set (MDS) dated [DATE], R12 needs substantial/maximal assistance, the helper does more than half the effort during shower activity. On 3/29/2025 at 2:00 pm, R11 (R12's family member) said, R12 does not get the showers twice a week, that is the reason R12 is not clean. R12 was observed to have oily hair and grime on her face. On 3/30/2025 at 10:35 am, V2 (DON) said R12's scheduled shower days are Wednesdays and Saturdays during 3-11 shift. Per our electronic medical record, R12 received a shower on 3/5 and 3/26/2025. R12 was supposed to be showered on 3/8, 3/15, 3/19,3/22, and 3/29/2025. I cannot find any documentation on those days. On 3/29/2025 at 9:20 am, V8 (Licensed Practical Nurse) said we have a shower schedule at the nurse station. The patients need to receive the showers as per the schedule. We will document if they refuse the shower; it is not acceptable not to give a resident a scheduled shower. On 3/29/2025 at 1:30 pm V16 (Certified Nursing Assistant) said, I am responsible to make sure to care for the residents and to provide the showers as per the schedule we have posted at the nurse station. If the resident refuses the shower, I tell the nurse and the nurse needs to follow up with the patient. I document when I give a shower in electronic medical record. Since last month, they are not using paper forms. On 3/30/2025 at 10:46 am, V2 (DON) presented the policy titled: Shower and Tub Bath dated 1/31/2018, which reads: to ensure resident's cleanliness to maintain proper hygiene and dignity. A shower will be offered according to the resident's preference two times per week or according to the resident's preferred frequency and as needed or requested. V2 said the resident's shower should be given on the days the shower is scheduled for, and if the patient refused it, the nurse must document it is unacceptable to have unsigned showers. 145197 Page 3 of 3