Health inspection·May 15, 2025

F 0687 Provide appropriate foot care. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy for nail care by failing to observe the condition of R2's toenails during weekly skin assessments and bathing, failed to document observations, and failed to provide podiatry services for one (R2) of three residents reviewed for foot care. This failure resulted R2 developing Onychomycosis, toe pain, toenail dystrophy with Onycholysis, subungual debris, and painful elongated toenails. Residents Affected - Few Findings include: R2's current diagnoses include but are not limited to Peripheral Vascular Disease, Alzheimer's Disease, Hypertension, and chronic kidney disease. R2 was admitted to the facility on [DATE]. R2's care plan dated 3/14/2025 states in part: R2 is an older adult who scores low on the BIMS cognitive assessment and is noted to have impaired cognitive function, poor memory recall, and poor safety and environmental awareness that impact level of alertness, decision making tasks, and ability to complete tasks independently r/t dementia. I am at risk for alteration in skin integrity. Risk factors: use of anti-coagulant, h/o skin impairments, incontinence, decrease mobility, requires assist with ADLs (activities of daily living). Intervention: observe skin daily with ADL care and report changes to the nurse. 4/12/2019. I have an arterial/ischemic ulcer of the Left Lower Leg r/t Peripheral Arterial Disease, Vascular Insufficiency. Inspect the feet daily, especially between the toes. Report changes to the nurse. 3/14/2025. On 5/12/25 at 10:37 AM, V4 (Certified Nursing Assistant/CNA) assisted with removing R2's socks to observe her bilateral toenails. R2's bilateral toenails appear to have been cut recently. There is no redness, drainage, discoloration, or odor noted. R2 was inquired of her toenails. R2 said, I don't remember when the doctor came for my feet. On 5/12/25 at 12:12 PM, R2 is up in her wheelchair. She appears to be clean, well-groomed, and appropriately dressed. She is wearing socks and shoes. She is self-propelling her wheelchair. On 5/12/25 at 1:36 PM, V11 (Social Service Director/SSD) was inquired of R2's foot care by podiatry. V11 said, Residents are seen every other month and they service one side of the building. It's split every month. I get (electronic fax) documentation when the podiatrist is coming, and it lists what sides of the building he will see. The podiatrist has a list of residents when he comes to the building. We email or call the podiatry office to put residents on the list to be seen. R2 was recently seen last week. The nurse gave me report that the family requested for her to see podiatry. R2's nurse called the podiatrist to see her. She's been here longer than I've worked here. I think she's been seen every 60 days. Page 1 of 4 145197 145197 05/15/2025 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0687 Level of Harm - Actual harm Residents Affected - Few There is no documentation of a nurse speaking with V18 (Family Member) in R2's progress notes. V2 (Director of Nursing/DON) provided the concern form she completed on 5/4/2025 regarding V18's (Family Member) concern about toenail care and discoloration of toenails. R2's podiatry care was requested for review from January 2024 to current. V11 (SSD) to provide the facility podiatry list from January 2025 to current. Upon review, R2 is not listed as being seen by the podiatrist. On 5/12/25 at 2:16 PM, V13 (Licensed Practical Nurse/LPN) was inquired of R2's foot care. V13 said, R2 got her nails clipped last week. I helped the podiatrist. I lifted her feet. She didn't complain of pain to me. No problems after it. V13 reviewed R2's medication administration record. She hasn't had any concerns with the medicine for her toes. She's been getting it at night. On 5/13/25 at 9:43 AM, V15 (LPN) was inquired of R2's foot care. V15 said, I wasn't here when her family came. It was reported to me her family had concerns with her foot care. I relayed the message to social service. I put in a request for her to be seen by the podiatrist. R2 didn't have issues with her feet prior to the request that I was aware of. On 5/13/25 at 10:31 AM, V16 (Wound Care Nurse/LPN) was inquired of R2's foot care. V16 said, V2 (DON) told me in morning meeting to see R2 and I put in a note. R2 hadn't complained to me prior to that day. I tried to call the family, but no one responded. V2 asked me to look at her feet and document what I saw. Her toenails were overgrown, hard, yellow in color, and thickened. It happens with age. There haven't been any concerns with her medicine. V11 (Social Service) contacted her podiatrist, and he came in the next day. On 5/13/25 at 11:44 AM, V2 (DON) was inquired of R2's foot care. V2 said, Prior to this visit the family or R2 didn't have concerns. I found out on 5/5/25 because there was a grievance from the family. I asked social service to see how soon we could get the podiatrist out to see her. I called the POA to let him know. I asked V16 (Wound Care/LPN) to see R2. On 5/6/25 V17 (Nurse Practitioner) assessed her. V16 ordered a topical medication to be applied at bedtime for six months. She deferred the oral medication due to possible liver damage. POA was notified as well as other family member. V11 (SSD) handles the podiatrist, I'm not sure how often they come in. I haven't seen the POA, or family come in since R2's been treated by the podiatrist. I'll check for the follow up documentation from the podiatrist. On 5/13/25 at 12:21 PM, V1 (Administrator) was inquired of R2's foot care provided by the podiatrist. V1 said, I spoke with the podiatrist's office, and they don't have any notes after July 2024 for R2. They forgot her off their list. They generate their own list from (electronic medical record) when they come in. R2 was last seen by the podiatrist on 5/9/2024 and 7/13/2024. She had not been seen for 9 months until R2's family requested for toenail care. R2's shower sheets were reviewed from January to April 2025. There is no documentation on the condition of her toenails. R2's shower days are every Wednesday and Saturday. V2 (DON) was to provide her May 2025 shower sheets for review. V2 provided R2's shower sheets with skin checks for review. The 5/6/25 sheet documents R2's family requested her to be seen for her toenails. 145197 Page 2 of 4 145197 05/15/2025 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0687 Level of Harm - Actual harm Residents Affected - Few On 5/14/25 at 9:00 AM, V2 was inquired of the resident skin assessments. V2 said, The nurses do weekly skin assessments, it should be head to toe. They check for any skin alterations. They should document it and do a follow up if needed. For R2 they should put in a podiatry consult and notify all appropriate parties. The CNAs (Certified Nurse Assistant) do showers weekly, document it on the shower sheet and notify the nurse of any skin alterations. Review of R2's weekly nursing skin assessment scheduled every day shift on Wednesday for skin integrity monitoring from January 2025 through April 2025 documents some assessments were completed, but there was no documentation of her toenail overgrowth and fungus presence. There were also multiple dates not documented as being performed. R2's progress notes on 5/5/25 by V17 (Nurse Practitioner) document R2's history of PVD (Peripheral Vascular Disease). Review of R2's progress notes state in part: On 5/6/26 at 10:25 AM, V16 (Wound Care/LPN) assessed R2's toenails as being overgrown, needing cutting, thick and yellow in color. Recommended to see podiatry. On 5/6/25 at 12:11 PM, V16 called V18 (Family Member) and left a message. On 5/6/25 at 1:03 PM, V19 (Podiatrist) scheduled to visit R2. On 5/6/25 at 1:06 PM, V17 (NP) prescribed Ciclopirox External Solution 8 % (Ciclopirox) Apply to toenails bilaterally topically at bedtime for Onychomycosis (a nail fungus causing thickened, brittle, crumbly, or ragged toenails) for 6 Months. Apply evenly over the entire nail plate and 5 mm (millimeters) of surrounding skin. Daily applications should be made over the previous coat and removed with alcohol every 7 days. This cycle should be repeated throughout the duration of treatment. On 5/6/26, time undocumented, V19 (Podiatrist) assessed R2 stating in part: Right and Left toenails: Nail dystrophy (thickened, discolored or deformed), discolored nails with Onycholysis (detachment of the nail from the nail bed), subungual (beneath the nail) debris, and painful elongated toenails. Impression: Onychomycosis (a nail fungus causing thickened, brittle, crumbly, or ragged toenails). Associated diagnosis: Toe pain. Plan: Toenail Debridement with findings. Note: R2 was seen as an emergency visit. Seen with RN (Registered Nurse) and V11 (SSD). After visit, POA (Power of Attorney) was called with V11 and informed of treatment. Risks to the liver from oral antibiotics were reviewed with POA. Patient primary physician prescribed Ciclopirox to be applied daily to toenails. Will continue to monitor and see patient again in 9 weeks. The facility assessment dated [DATE] states in part: indicate if you may accept residents with or your residents may develop the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. Category: Heart/Circulatory System: Peripheral Vascular Disease. Staff competencies necessary to provide the level and types of care needed for the resident population: hygiene & bathing (oral care, nail care, shaving, grooming etc.) Targeted audience: Licensed nurses and nurse aides. Staffing and Personnel: total number needed: contracted services- podiatrist (1). The 1/25/2018 Nail Care Policy states in part: 145197 Page 3 of 4 145197 05/15/2025 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0687 1. Observe condition of resident nails during each time of bathing. Note cleanliness, length, uneven edges, hypertrophied nails (abnormal thickening of the nail plate on the feet or hands). Level of Harm - Actual harm 6. Podiatry services may be required for residents with PVD (Peripheral Vascular Disease). Residents Affected - Few 10. Document provision of care and pertinent observations. 145197 Page 4 of 4