Health inspection·May 30, 2025

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a physician ordered referral to a specialist was initiated and facilitated for one resident (R1) of three residents reviewed for community medical appointments. Residents Affected - Few The findings include: On 5/30/25 at 9:45am R1 stated he was set up with an appointment for an Orthopedic appointment at a medical center for his arthritis. R1 stated he couldn't go, and the Administrator told him he had to find his own transportation as it was too far for the facility van to take him. R1 stated he did ask to be transferred to another facility that would be closer to the medical center, however I'm still here. Office Clinic Physician Note dated 3/1/24 indicates R1 was evaluated for bilateral hand issues. Note indicates R1 has a history of a right thumb amputation due to an infection about 2 years ago. R1 reported he is unable to take care of himself due to this impairment. Note indicates R1 questioned the possibility of a transfer to create a thumb and inquired about this procedure as an option. Physical Exam indicates Exam of right hand reveals significant contractures of the four remaining fingers of his right hand. (R1's) thumb was amputated at the level of the MP (metacarpophalangeal) joint. The contractures of the fingers are not passively correctable at this point. (R1) has some significant contractures on the left side as well. Assessment/Plan indicates Physician had an extensive discussion with (R1) explaining that I do not think there is much that can be done at this point regarding his finger contractures given their severity. (R1) would like to have a referral to an academic hand specialist for consideration of great toe transfer/pollicization. I explained to (R1) that I do not think he would be a good candidate for pollicization given his age and overall health but nevertheless (R1) is interested in a referral. Per his request we will go ahead and arrange that. Physician Order Sheet dated 3/1/24 at 11:34am indicates: Referral Management to Orthopedic Surgery (at a medical center), Multiple Finger Contractures; Possible great toe transfer/pollicization at a major medical center (approximately 2-3 hour drive from clinic). Care Plan Note Text dated 12/10/24 at 12pm indicates IDT (Interdisciplinary Team) met with R1 for care plan meeting. R1 is very upset as he needs a ride for a possible procedure to his hands, and the office where he would need to have it done is farther away than the facility will transport. Because of this, there would be a fee for transportation. R1 feels that this facility should pay for his transport to any facility he may need. Social Services Director has sent a referral to a facility of R1's choice, closer to where the procedure would take place. R1 was updated about the referral. Emotional support and encouragement provided. Will continue with current plan of care. (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 3 Event ID: 145200 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 145200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franklin Grove Living and Rehab 502 North State Street Franklin Grove, IL 61031 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)