Health inspection·January 8, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review the facility failed to notify the physician of an ongoing change in condition in a timely manner. This applies to 1 of 3 residents (R1) reviewed for notification of changes in the sample of 5. The findings include: R1's eINTERACT change in condition evaluation dated December 18, 2024, shows, she had a change in condition of weakness that started the morning of December 18, 2024. The same evaluation continues to show, V5 Nurse Practitioner (NP) was notified of the changes, and nothing was ordered or done. On January 8, 2024, at 12:48 PM, V5 NP stated she did not recall if she was notified of R1's change in condition or not. There was nothing documented in R1's chart that showed she was. I get so many messages; I can't remember them all. R1's progress notes continue to show, her condition stays the same with no changes. R1's electronic medical records did not show any other documentation that R1's primary care physician or Nurse Practitioner were notified of any changes in condition from December 18th - December 22, 2024. On January 8, 2024, at 11:42 AM, V6 Registered Nurse (RN) stated, she worked with R1 on December 18th and 21st. R1 was having some weakness. She reported the original change in condition on December 18, 2024, to V5 NP however when she saw R1 again, she was the same as she was on the 18th. There was no improvement. She did not call the doctor on that day to update them on R1's condition. On January 8, 2024, at 12:13 PM, V9 RN stated, he worked with R1 on December 19th and 20th. He did not contact the doctor or let anyone know of her condition. As far as I know, my colleague did. The facility's physician-family notification-change in condition policy dated November 13, 2018, shows, Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. Guidelines: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); Life-threatening conditions are such things as heart attack or stroke. Clinical complications are such things as development of a stage II pressure Page 1 of 4 145261 145261 01/08/2025 Aperion Care Dekalb 1212 South Second Street Dekalb, IL 60115

F 0580 sore, onset of recurrent periods of delirium, recurrent urinary tract infection, or onset of depression . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145261 Page 2 of 4 145261 01/08/2025 Aperion Care Dekalb 1212 South Second Street Dekalb, IL 60115

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to identify and assess a resident for an ongoing change in condition. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 5. Residents Affected - Few The findings include: R1's face sheet lists her diagnoses to include: cerebral infarction, diabetes mellitus II, cerebral aneurysm, hemiplegia, adjustment disorder with anxiety and dementia. R1's eINTERACT change in condition evaluation dated December 18, 2024, shows, she had a change in condition of weakness that started the morning of December 18, 2024. The evaluation shows, she has weakness or hemiparesis, arm or leg: Gradual recent onset not resolving spontaneously. There is nothing else documented in R1's electronic medical record about her change of condition until December 21, 2024 (2 days later). R1's 72 hours charting progress notes dated December 21, 2024, at 2:06 PM and 6:08 PM show, Since the change in condition, the symptoms have remained the same. still weak and unable to feed herself. being assisted in eating. Vitals within normal limits. The physician that was notified was Name and Designation: (left blank). R1's 72 hours charting progress notes dated December 21, 2024, at 9:52 PM shows, Since change in condition, the symptoms have remained the same. assess residents' vitals WNL (within normal limits). The physician that was notified was Name and Designation: (left blank). R1's 72 hours charting progress notes dated December 22, 2024, at 6:50 AM shows, Late entry for 12/21 3am-7pm shift. The resident is still weak since the change in condition on the 18th. Vital signs WNL. was able to tolerate her pills. 50% of the house supplements were consumed for both AM and PM. was fed during breakfast and lunch in room on high fowler's position by the writer and the CNA (Certified Nursing Assistant), ate 25-35% for both meals. At dinner this resident was brought to dining room using hoyer to be assisted in feeding. CNA notified the writer; she consumed 25% as well. Plan of care is ongoing. R1's nurses notes dated December 22, 2024, at 6:50 AM shows, Resident was noted to have decreased oxygen saturation @ 86% not on labored breathing. Also looks dehydrated and weaker. PCP (primary care physician) advised that we can do 2 things either send to ER (emergency room) for evaluation and IV fluids or work up at the facility and employ more of a comfort approach. May follow up for hospice eligibility. POA (Power of Attorney) informed and chose to transfer the resident to ER. PCP informed about the POA's decision . R1's nurses notes dated December 22, 2024, shows, Resident admitted to local hospital with dx (diagnosis) of UTI (urinary tract infection) . On January 8, 2025, at 9:15 AM, V10 R1's Power of Attorney/daughter stated, the facility called her and told her that her mom looked off and they would do some labs to find out what was going on. A few days later, she hadn't heard anything from the facility about the laboratory results. She tried calling to find out what they were. No one knew what she was talking about or the results of the 145261 Page 3 of 4 145261 01/08/2025 Aperion Care Dekalb 1212 South Second Street Dekalb, IL 60115

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few labs. Then on December 22, 2024, the nurse called her and said her mom didn't look good and her eyes were sunken in. He asked if she wanted her mom to be sent to the emergency room (ER). She said, yes, bring her to the ER. R1 was admitted to the local hospital with dehydration and a UTI. On January 8, 2024, at 11:42 AM, V6 Registered Nurse (RN) stated, R1 was having some weakness (on December 18th). The CNA reported R1 was having a hard time eating and needed to be fed. She did a change of condition form and notified V5 NP. I can't remember the exact order. Typically, they will order some labs and a urinalysis (UA), but she couldn't remember if she did or not. She didn't work again until December 21, 2024. When she saw R1 again, she was the same as she was on the 18th. There was no improvement. She did not call the doctor on that day to update them on R1's condition. On January 8, 2024, at 12:13 PM, V9 RN stated, he worked with R1 on December 19th and 20th. As far as he knew R1 had a decline by not eating and sleeping more. He did not contact the doctor or let anyone know of her condition. As far as I know, my colleague did. On January 8, 2024, at 11:57 AM, V7 RN stated, he was the nurse that sent R1 to the hospital on December 22, 2024. He checked R1's vitals around 7 AM. Her oxygen saturation was low around 86%. She looked weak and dehydrated. He called the doctor to report his assessment. The doctor told her to either send her out to the hospital or treat her at the facility. He called the POA and the POA wanted her sent out, so he sent her to the local hospital. He did not work with her any other time during her change in condition. The facility did not provide a change in condition policy. The only policy provided was notification of change in condition policy. The facility's physician-family notification-change in condition policy dated November 13, 2018, shows, Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. Guidelines: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); Life-threatening conditions are such things as heart attack or stroke. Clinical complications are such things as development of a stage II pressure sore, onset of recurrent periods of delirium, recurrent urinary tract infection, or onset of depression . 145261 Page 4 of 4