Health inspection·April 18, 2025

F 0774 Help the resident with transportation to and from laboratory services outside of the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a resident with transportation arrangements to and from a CT (computed tomography) scan, resulting in the resident missing multiple appointments and experiencing a delay in treatment for one (R3) resident out of three residents reviewed for resident rights in a total sample of five. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. Residents Affected - Few Findings include: On 4/16/2025, at 11:51 AM, V10 (Medical records/Transportation coordinator) states I come on a Monday. I run the report and see what appointments I have that week, or sometimes I review it on Friday to see for the next week. V10 states when we were using the ride-hailing service, it was easier. But now since I am back calling the insurance, I must check them beforehand since I must let them know at least 3 days in advance. V10 states facility ride-hailing service card ran out/declined on April 3rd, 2025. V10 states that V1 (administrator) told her that the card resets on the 14th of April. I had to go and see what I had, for Friday and the following week, if patients had appointments. I had to set up the transportation through their insurances. V10 states I know there has been some appointment problems for R3. We were setting up the appointments on the days that she has dialysis. I know recently I sent her out for this CT (computed tomography) appointment that you are talking about. She went out on April 11th, 2025, to the hospital at 9:00 AM. The ambulance stretcher came for her at 8:00 AM. V10 states that R3 needs assistance with transportation because she uses a wheelchair. V10 states that she received a call from the daughter. She was not upset. She was asking if we can get her to go sooner to get the CT scan because the neurosurgeon wants to see her sooner. V10 states that R3's neurosurgeon follow-up appointment is scheduled for May 6th, 2025. V10 reports that R3 was supposed to go out for the CT scan on March 27th, 2025, but my escort pulled out last minute because she had to go pick up her son. I told V14 (Licensed Practical Nurse) if we can reschedule the appointment. V10 states she (V14) told her that she will try to call and get the appointment rescheduled. I wasn't aware of any appointments that she had scheduled for April 1st, 2025. V10 states that R3 did not go to the appointment on March 27th, 2025, to get the MRI of head due to not having an escort. She didn't go to the March 28th, 2025, appointment due to the dialysis schedule. V10 states I didn't set up transportation for March 31st, 2025. I learned the importance after. V10 states that she left early from work on March 28th, 2025, from work. On 4/16/2025, 11:20 AM, V7 (Registered Nurse) states that for R3, I (V7) know that there have been a few missed appointments. I don't know exactly what happened. The lady on the phone from the CT (computed tomography) place, was kind of upset. We made it happen for her to go the next day. V7 states that she does not know why she missed appointments. V7 reports that she contacted V10 (Medical records/Transportation coordinator) that she (R3) needs to go to her appointment. V7 states that R3 had Page 1 of 3 145450 145450 04/18/2025 Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640

F 0774 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few an appointment on Friday March 28th, 2025, at 3:00 PM. She had her dialysis that same day. Usually R3's dialysis time is at 12:30 PM and lasts 3-4 hours. V7 states that the lady on the phone from the CT place told her they can see her on Monday March 31st, 2025, at 2:20 PM. V7 continues to state I called V10, that she (R3) had an appointment on Monday March 31st, 2025 R3 has dialysis on Monday, Wednesday, and Friday. But I had spoken to the dialysis staff if we could move her time to the morning. Usually V11 (Dialysis Nurse/Registered Nurse) says its ok. V7 states that the importance of R3 having the CT scan of her head done is to avoid delay in care. V7 continues their condition can get worse if something is going on and other things can start happening to them. On 4/16/2025, 1:09 PM, V11 (Registered Nurse/Dialysis nurse) states that for dialysis, they make sure the residents stick to their dialysis schedule because dialysis is more important. They contact us (usually the transportation coordinator) if they cannot reschedule their appointment. We do try to coordinate with a different schedule for that specific dialysis day. We try to put dialysis first. It's still safe to change the time of dialysis as long as it's on the same treatment day. V11 states that V7 (Registered Nurse) did contacted her regarding R3's appointment for Monday March 31st, 2025, at 2:20 PM. V11 states that she informed V7 that she cannot change the date and time due to the acuity of other patients on that Monday. V11 states, I guess they rescheduled her MRI (magnetic resonance imaging) for another day. V11 continues to report that on Thursday V10 (Medical records/Transportation coordinator) sent me (V11) a message, regarding R3's Friday appointment. I rescheduled R3's dialysis schedule from the 2nd sitting which is from (12:00 PM-4:00 PM) to the 3rd sitting which is from (4:00 PM-8:00 PM). V11 states the 1st sitting is between 6:30 AM-10:30 AM. V11 reports that V10 sent her the message on Thursday around 5:00 PM. V10 informed her that R3's appointment was around 2:00 PM. On 04/17/2025, at 1:54 PM, V14 (Licensed Practical Nurse) states that when R3 missed her initial appointment she had to have an MRI scan, which was on March 27th, 2025, due to escort issues. She called to reschedule the MRI scan for the following day. V14 states that she informed V10 (Medical records/Transportation coordinator) that it would conflict with R3's dialysis time. V10 told V14 that she was going to ask dialysis nurse if R3 can switch to a different time. V14 states that she didn't work the following day and she does not know why R3 didn't go the next day either. On 04/16/2025, 3:02 PM, via telephone V12 (Registered Nurse) states that she works for the facility through an agency. V12 continues to state I've worked here more than once. What I can remember for R3's appointment situation is I got a call from the neurosurgeon department. They called and said they were going to change the date because she (R3) had to get the MRI (magnetic resonance imaging) before the appointment. She called me and faxed the paperwork. V12 continues to state I put in the order that same day that I received that information. I was working a 12-hour shift, 7:00 AM to 7:00 PM. R3's Face sheet documents that R3 is an [AGE] year-old individual admitted to the facility on [DATE], who has diagnoses not limited to: traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, end stage renal disease, dependence on renal dialysis. R3's hospital paperwork dated 03/18/2025, documents in part, after visit summary, please call to schedule your follow up non-contrast CT (computed tomography) scan. Scan must be completed prior to your follow up appointment scheduled on 03/25/2025. Follow-up visit with neurosurgeon on 03/25/2025 at 8:45 AM. 145450 Page 2 of 3 145450 04/18/2025 Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640

F 0774 Level of Harm - Minimal harm or potential for actual harm R3's nurses note dated 03/24/2025, 2:23 PM, documents in part writer (V12) got a call from neurosurgery that resident (R3) has an appointment on 03/25/25, but she needs to go for an MRI before the appointment. Resident's appointment was change and moved, MRI (magnetic resonance imaging) appointment on 3/27/25, at 4:40 PM. Pt. (patient) to arrive at 4:10 PM. Follow up appointment with Neurosurgery on 4/1/25, at 11:30 AM. PT (patient) to arrive at 11:00 AM. Residents Affected - Few R3's physician order set documents in part MRI (magnetic resonance imaging) appointment on 3/27/25 (Thursday) at 4:40 PM. Pt. (patient) to arrive at 4:10PM. R3's physician order set documents in part Follow up appointment with Neurosurgery on 4/1/25 (Thursday) at 11:30 AM. R3's physician order set documents in part MRI appointment on 3/28/2025, at 3:00 PM. Please call for transportation. R3's physician order set documents in part MRI appointment on 3/31/2025, at 2:20 PM. Please call for transportation. R3's physician order set documents in part Appointment: 4/11/25, at 9:00 AM for CT scan needed prior to Neurosurgery follow up. Please schedule transportation. Facility document dated 09/2020 titled transportation documents in part the facility will assist residents in arranging for transportation as needed. 145450 Page 3 of 3