Health inspection·August 27, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a resident's dignity when a staff member is feeding a resident (R4) seated in a wheelchair in a total sample of 5 residents (R1, R2, R3, R4 and R5) reviewed for improper nursing care.Findings include:On 8/25/2025 at 11:54 AM, R4 observed sitting in R4's wheelchair positioned in front of a table in the dining room with lunch meal tray in front of R4, and R4's lunch meal consists of a mechanical soft texture meal.On 8/25/2025 at 12:05 PM, V3 (Licensed Practical Nurse, LPN) observed walking up to the side of R4, who remains seated in R4's wheelchair at the dining room table and stands next to R4. While in a standing position over R4, V3 picks up spoon and begins to feed R4 mechanical soft food from the tray. V3, while standing, continues to feed R4 over 10 spoons of food from R4's tray.R4's admission Record documents, in part, diagnoses of dementia, dysphagia, convulsions, epilepsy, chronic obstructive pulmonary disease, type 2 diabetes mellitus, cardiomegaly, hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, atherosclerotic heart diseases of native coronary artery without angina pectoris, pneumonia, abnormalities of gait and mobility, lack of coordination, personal history of other malignant neoplasm of skin, sleep apnea, major depressive disorder, hearing loss, obstructive sleep apnea, primary osteoarthritis, and hyperlipidemia.R4's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R4 has severe cognitive impairment. R4's Swallowing/Nutritional Status shows that R4 is on a mechanically altered diet (required change in texture of food or liquids) and therapeutic diet (low salt, diabetic, low cholesterol).On 8/27/2025 at 9:25 AM, V2 (Director of Nursing, DON) stated that all nurses and CNAs (Certified Nursing Assistants) are trained when they are feeding a resident, they must sit in front of the resident, at the same eye level as the resident. V2 stated that not standing above a resident while feeding is a resident's right of dignity and respect. Also, V2 stated that the nurse feeding a resident with the face-to-face approach allows for the nurse to check the resident for swallowing or choking concerns while the resident is chewing and swallowing.R4's Care Plan (date initiated 11/23/2022, revision on 11/16/2023) documents, in part, a focus of R4 having a swallowing problem of dysphagia as evidenced coughing or choking during meals and difficulty with thin liquids secondary to baseline dementia and history of aspiration pneumonia. R4's interventions include for all staff to be informed of R4's special dietary and safety needs; eat with supervision only; and monitor/document/report as needed signs of symptoms of dysphagia such as pocketing, choking, coughing, or drooling.R4's Order Summary Report documents, in part, a physician order (dated 7/29/2025) of mechanical soft texture, nectar thick liquids consistency, and consistent carbohydrate diet with supervision for small bites.Facility policy titled Dignity and dated 4/23/2018 documents, in part, Guidelines: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality . Page 1 of 2 145591 145591 08/27/2025 Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Maintaining a resident's dignity should include but is not limited to the following: . Promoting resident independence and dignity while dining, such as avoiding: . Staff standing over residents while assisting them to eat.Facility policy titled Resident Rights and dated 1/4/2019 documents, in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. 145591 Page 2 of 2