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. Page 1 of 3 145200 145200 05/30/2025 Franklin Grove Living and Rehab 502 North State Street Franklin Grove, IL 61031

F 0745 Level of Harm - Minimal harm or potential for actual harm Current Care Plan (5/2025) did not include referral to a medical center and/or transportation, insurance or payment issues related to this referral. No other facility progress notes were found or presented regarding efforts by the facility to obtain transportation for the referral made on 3/1/24. Residents Affected - Few On 5/30/25 at 10:45am V6 (Transportation) stated the facility van only takes residents to local appointments. V6 stated the medical center would not be local and would be set up differently by V1 (Administrator). V6 stated she has no knowledge about what was being done for the referral for R1. On 5/30/25 at 11:30am V1 (Administrator) stated V2 (Director of Nursing/DON) is working with insurance the last couple weeks to see if they will help with transportation for R1. V1 stated we don't typically document about referrals and transportation needs. On 5/30/25 at 11:45am V4 (Social Service Director/SSD) stated she was not involved in the referral for R1 to go to the medical center. V4 stated that R1 wanted to be transferred to another long-term care facility closer to the medical center if he could not get assistance with transportation from the facility. V4 stated she had sent out several referrals to different facilities closer to the medical center however all were declined. V4 stated she did not keep the actual referrals sent to the facilities. Social Service Note dated 12/31/24 at 2:41pm indicates In the last month, I have sent referrals out to facilities for R1. The following have refused to take him (four local facilities were named). I talked with (R1) and told him to let me know if there is anywhere else, he would like me to check into. He has not given me any other facilities to check. The above Social Service Note dated 12/31/24 was the last documentation regarding referrals for R1 found or presented. On 5/30/25 at 1:10pm V2 (DON) stated I don't know where we are with (R1's) referral. V2 stated V4 (SSD) took the call from R1's insurance. V2 stated she only deals with clinical issues for residents. V2 stated the surgery R1 wants would be considered Elective and doesn't believe insurance would cover the procedure, but never spoke to anyone so really doesn't know. On 5/30/25 at 1:15pm V4 (SSD) stated I did not contact R1's insurance and never received a call from R1's insurance. On 5/30/25 at 3:30pm V1 (Administrator) acknowledged facilitating medical appointments and referrals to other facilities should be addressed by Social Service and documented as to progress of those referrals. Social Service Designee Job Description indicates: The primary purpose of your job position is to assist in planning, developing, organizing, implementing, evaluating, and directing our facility ' s social service programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. 145200 Page 2 of 3 145200 05/30/2025 Franklin Grove Living and Rehab 502 North State Street Franklin Grove, IL 61031

F 0745 Job Functions: Level of Harm - Minimal harm or potential for actual harm Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position. Residents Affected - Few Responsibilities and Duties/Essential Functions: Refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. Record and maintain regular Social Service progress notes indicating response to the treatment plan and/or adjustment to institutional life. Assist in providing solutions for social and practical environmental problems including seeking financial assistance, discharge planning (including collaboration with community agencies), and referrals to other community agencies when specialized assistance is required. 145200 Page 3 of 3